Rezumatul tezei de doctorat

CORELAII CLINICO-IMAGISTICE N SCOPUL STABILIRII UNEI CONDUITE TERAPEUTICE

OPTIMALE N URGENELE BILIO-PANCREATICE
CONDUCTOR TIINIFIC: PROF. DR. RADU BADEA
DOCTORAND: ADELA GOLEA
Cluj Napoca 2010
CUVINTE CHEIE: ultrasonografie, urgene bilio-pancreatice, colecistit acut, afeciune acut de ci biliare,
pancreatit acut, corelaie clinico-imagistic, examinare de prim intenie, algoritm diagnostic, ultrasonografie
cu contrast.
CUPRINS
INTRODUCERE _____________________________________________________________________________________________________ 4
PARTEA GENERAL. STADIUL ACTUAL AL CUNOATERII ____________________________________________________________ 5
CAPITOLUL I. URGENELE BILIO-PANCREATICE ____________________________________________________________________ 6
I.1. CADRUL NOSOLOGIC _________________________________________________________________________________________ 6
I.1.1. Definirea urgenelor bilio-pancreatice ____________________________________________________________________ 6
I.1.2. Integrarea n cadrul urgenelor medico-chirurgicale _________________________________________________________ 8
I.2. INCIDEN _________________________________________________________________________________________________ 9
I.3. DATE EPIDEMIOLOGICE ______________________________________________________________________________________ 11
I.3.1. Litiaza biliar ______________________________________________________________________________________ 11
I.3.2. Pancreatita acut ___________________________________________________________________________________ 12
I.4. PATOGENEZ ______________________________________________________________________________________________ 14
I.4.1. Patogeneza litiazei biliare_____________________________________________________________________________ 14
I.4.2. Patogeneza complicaiilor litiazei biliare _________________________________________________________________ 16
I.5. NECESAR DE RESURSE UMANE, MATERIALE I INFRASTRUCTUR ______________________________________________________ 18
CAPITOLUL II. EXPLORRI IMAGISTICE FOLOSITE N URGENELE BILIO-PANCREATICE ____________________________ 20
II.1. ENUMERARE. PERFORMAN. INDICAII. LIMITE __________________________________________________________________
II.2. PROTOCOALE DIAGNOSTICE N URGEN ________________________________________________________________________
II.2.1. Colica biliar litiaza biliar colecistita acut __________________________________________________________
II.2.2.Litiaza de cale biliar colangita acut _________________________________________________________________
II.2.3. Pancreatita acut biliar _____________________________________________________________________________

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CAPITOLUL III. ULTRASONOGRAFIA N URGENE I STRI CRITICE_________________________________________________ 30

III.1. DEFINIREA METODEI _______________________________________________________________________________________ 30
III.2. TEHNICI FOLOSITE _________________________________________________________________________________________ 30
III.3. PARTICULARITI ALE EXAMINRII ULTRASONOGRAFICE N URGEN_________________________________________________ 38
CAPITOLUL IV. CRITERII DE APRECIERE A SEVERITII URGENELOR BILIO-PANCREATICE I IMPACTUL ASUPRA
MANAGEMENTULUI _______________________________________________________________________________________________ 42
CAPITOLUL V. MOTIVAREA CERCETRII ___________________________________________________________________________ 45
V.1. LIMITELE DIAGNOSTICULUI CLINIC _____________________________________________________________________________
V.2. PARTICULARITILE DIAGNOSTICULUI N URGEN ________________________________________________________________
V.3. IMAGISTICA N URGEN SIMULAREA UNEI SITUAII IDEALE ______________________________________________________
V.4. ULTRASONOGRAFIA PORTABIL _______________________________________________________________________________

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PARTEA SPECIAL. CONTRIBUII PROPRII _________________________________________________________________________ 49

CAPITOLUL I. SCOPUL STUDIULUI: PREMISE I OBIECTIVE GENERALE ______________________________________________ 50
CAPITOLUL II. METODOLOGIE _____________________________________________________________________________________ 51
CAPITOLUL III. METODE STATISTICE UTILIZATE ___________________________________________________________________ 53
CAPITOLUL IV. ULTRASONOGRAFIA CA PRIM METOD DE DIAGNOSTIC IMAGISTIC UTILIZAT N URGENELE BILIOPANCREATICE (STUDIUL I) ________________________________________________________________________________________ 55
IV.1. OBIECTIVE _______________________________________________________________________________________________ 55
IV.2. MATERIAL I METOD _____________________________________________________________________________________ 55
IV.3. REZULTATE ______________________________________________________________________________________________ 59

IV.4. DISCUII ________________________________________________________________________________________________ 77

IV.5. CONCLUZII ______________________________________________________________________________________________ 83
CAPITOLUL V. ULTRASONOGRAFIA N URGENELE BILIARE PATOLOGIA COLECISTULUI - STUDIUL II ______________ 85
V.1. OBIECTIVE _______________________________________________________________________________________________ 85
V.2. MATERIAL I METOD ______________________________________________________________________________________ 85
V.3. REZULTATE ______________________________________________________________________________________________ 87
V.4.DISCUII ________________________________________________________________________________________________ 100
V.5. CONCLUZII ______________________________________________________________________________________________ 104
CAPITOLUL VI. ULTRASONOGRAFIA N AFECIUNI ACUTE ALE CILOR BILIARE - STUDIUL III ______________________ 106
VI.1. OBIECTIVE ______________________________________________________________________________________________
VI.2. MATERIAL I METOD ____________________________________________________________________________________
VI.3.REZULTATE _____________________________________________________________________________________________
VI.4. DISCUII _______________________________________________________________________________________________
VI.5. CONCLUZII _____________________________________________________________________________________________

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CAPITOLUL VII. ULTRASONOGRAFIA N PANCREATITA ACUT - STUDIUL IV _______________________________________ 116

VII.1. OBIECTIVE _____________________________________________________________________________________________
VII.2. MATERIAL I METOD ____________________________________________________________________________________
VII.3. REZULTATE ____________________________________________________________________________________________
VII.4. DISCUII_______________________________________________________________________________________________
VII.5. CONCLUZII _____________________________________________________________________________________________

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CAPITOLUL VIII. ULTRASONOGRAFIA CU CONTRAST N PANCREATITA ACUT - STUDIUL V _________________________ 139

VIII.1. OBIECTIVE ____________________________________________________________________________________________
VIII.2. MATERIAL I METOD ___________________________________________________________________________________
VIII.3. REZULTATE____________________________________________________________________________________________
VIII.4. DISCUII ______________________________________________________________________________________________
VIII.5. CONCLUZII ____________________________________________________________________________________________

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CAPITOLUL IX. DISCUII GENERALE. ALGORITMI DE DIAGNOSTIC. ROLUL ULTRASONOGRAFIEI N URGENELE BILIOPANCREATICE ___________________________________________________________________________________________________ 171
CAPITOLUL X. CONCLUZII FINALE I CONTRIBUII PERSONALE ___________________________________________________ 176
BIBLIOGRAFIE ___________________________________________________________________________________________________ 179

Introducere
Dezvoltarea i perfecionarea tehnicii de explorare ultrasonografic, precum i posibilitatea efecturii acesteia
la nivelul serviciului de urgen a determinat apariia de noi dovezi practice ale optimizrii managementului
diagnostico-terapeutic al urgenelor bilio-pancreatice, constituind baza de pornire pentru alegerea temei de cercetare:
CORELAII CLINICO-IMAGISTICE N SCOPUL STABILIRII UNEI CONDUITE TERAPEUTICE OPTIMALE N
URGENELE BILIO-PANCREATICE.
Lucrarea elaborat i-a propus cercetarea aportului metodei ultrasonografice la nivelul Unitilor de Primiri
Urgene, n vederea optimizrii triajului i a conduitei diagnostico-terapeutice. Teza este alctuit din dou mari
capitole: partea general care realizeaz o sintez a datelor din literatur i partea special destinat cercetrilor
personale.
PARTEA GENERAL - STADIUL ACTUAL AL CUNOATERII
Diagnosticul durerii abdominale acute n departamentele de urgen reprezint una dintre frecventele provocri
diagnostice pentru medicul practician, reprezentnd n medie 5% din consultaii. Evoluia tehnologic i creterea
necesitii de rspuns a corpului medical n faa diversitii patologiei medicale a condus la apariia aparatelor portabile
de investigaie imagistic, definindu-se n literatur noiunea de bedside ultrasound, examinare la patul pacientului
critic. Ultrasonografia n urgenele bilio-pancreatice se dezvolt astfel ca o metod de gndire binar, capabil s
rspund la ntrebrile frecvente ale clinicianului: a).este litiaz biliar sau nu? b).exist complicaii ale litiazei biliare:
colecistit acut, litiaz coledocian, pancreatit acut? c).care este cauza icterului? d).care este cauza durerii
abdominale cu oc: anevrismul de aort abdominal complicat, pancreatita acut, colangita acut, infarctul intestinomezenteric?

Ultrasonografia este o metod rapid de diagnostic n urgen, permind triajul pacienilor cu patologie de
tip urgen major care necesit terapie chirurgical imediat, de cei la care este necesar terapie chirurgical n
urgen amnat sau conservatorie/intervenional, selectnd totodat i pacienii care necesit alte investigaii
imagistice pentru precizarea diagnosticului. Medicii de urgen au adoptat ultrasonografia ca standard de explorare a
multor tablouri clinice critice, pentru a scdea timpul de intervenie i a crete acurateea diagnostic.
Strategia terapeutic a urgenelor bilio-pancreatice necesit evaluare n trepte i management imediat, dar i
la distan n funcie de severitatea bolii i complicaiile decelate la evaluarea n urgen. Pentru o abordare optim este
necesar o apreciere a riscului utiliznd parametrii clinici, biologici i imagistici. Ultrasonografia prin accesibilitatea ei
poate furniza informaii suport pentru triajul pacienilor cu risc i trimiterea acestora spre centre specializate de
gastroenterologie.
Situaia ideal n urgen trebuie s aib un standard de referin, reprezentat de criteriul prin care se decide
dac pacientul are sau nu o boal. Ultrasonografia utiliznd aparatele miniaturizate, portabile ofer posibilitatea
abordrii practice a examinrii la patul pacientului (bedside ultrasonography), un deziderat mult dorit de medicii de
urgen i intensiviti.
PARTEA SPECIAL - CONTRIBUII PROPRII
Premisele studiului, ipotezele de lucru, materialul i metoda sunt prezentate pe larg n capitolele I, II, III.
Obiectivele propuse n cadrul prezentei cercetri sunt:
1. Realizarea unor corelaii ntre criteriile clinice i cele ultrasonografice n urgenele bilio-pancreatice care
s permit reducerea erorilor de diagnostic n departamentele de urgen;
2. Identificarea i precizarea performanelor metodei ultrasonografice n urgenele bilio-pancreatice privitor
la: diagnosticul de boal, diagnosticul de complicaie, criteriul de evolutivitate (prognostic);
3. Identificarea factorilor de punere la punct a unui algoritm diagnostic, bazat pe elemente clinice i
ecografice n urgenele bilio-pancreatice;
4. Analiza critic a metodei ultrasonografice n urgen identificarea principalilor factori care limiteaz
performanele metodei sau reprezint factori de eroare diagnostic.
Cercetarea s-a realizat secvenial prin 5 studii, 3 de tip retrospectiv i 2 de tip prospectiv n perioada august 2004
iulie 2010. Pacienii cuprini n studiu au fost selectai dintre cei care s-au prezentat n Departamentul de Urgen al
Spitalului Clinic de Urgen Octavian Fodor din Cluj i care ndeplineau criteriile de selecie stabilite pentru fiecare
domeniu de cercetare:
I.
Studiul referitor la ultrasonografie ca prim metod de diagnostic imagistic utilizat n urgenele biliopancreatice;
II.
Studiul referitor la rolul ultrasonografiei n patologia acut litiazic a colecistului;
III.
Studiul referitor la aportul ultrasonografiei n diagnosticul afeciunilor acute obstructive ale cilor biliare;
IV.
Studiul referitor la evaluarea rolului ultrasonografiei clasice n diagnosticul i evaluarea severitii n
pancreatita acut;
V.
Studiul referitor la evaluarea rolului ultrasonografiei cu contrast n evaluarea severitii pancreatitei acute.
Capitolul IV: Ultrasonografia ca prim metod de diagnostic imagistic utilizat n urgenele biliopancreatice (Studiul I)
Lotul A pacienii cu tablou clinic de urgen bilio-pancreatic
Studiul a fost de tip retrospectiv observaional, evalund rolul ultrasonografiei la pacienii cu tablou clinic acut
de tip bilio-pancreatic, care s-au prezentat n U.P.U. a Spitalului Clinic de Urgen O. Fodor, n perioada 6 decembrie
2005 30 decembrie 2006. Au fost cuprini n studiu 759 de pacieni, avnd vrsta cuprins ntre 17 ani i 90 de ani.
Lotul B pacienii cu tablou clinic de sindrom dureros de etaj abdominal superior de tip dispeptic
ulceros rezistent la terapia clasic
Studiul a fost de tip retrospectiv observaional evalund rolul ultrasonografiei n diagnosticul pacienilor care pot
constitui urgene bilio-pancreatice n contextul prezentrii cu sindrom clinic atipic. Lotul a cuprins un numr de 358 de
pacieni, care s-au prezentat n U.P.U., n perioada 6 decembrie 2005 30 decembrie 2006, cu vrste cuprinse ntre 19
ani 86 de ani (2.39% din totalul pacienilor care s-au adresat la U.P.U.) cu sindrom dureros de abdomen superior de
tip dispeptic ulceros rezistent la terapia clasic. Acest lot a fost selectat dintr-un numr de 534 de pacieni cu aceast
simptomatologie (3.55% din totalul pacienilor care s-au adresat la U.PU.).

IV.3. Rezultate
Lotul A de pacieni
Analiza descriptiv:Cei 759 de pacieni care s-au prezentat i au fost selectai n U.P.U. cu sindrom clinic de
urgen bilio-pancreatic au avut vrsta cuprins ntre 17 ani 90 de ani, cu o vrst medie de: 56.67 16.76 ani. Se
observ o prevalen semnificativ a patologiei acute bilio-pancreatice dup vrsta de 20 de ani, aceasta dublndu-se la
grupa de vrst 40 59 de ani. (Tabelul V)
Tabelul V. Repartiia procentual pe grupe de vrst a pacienilor cu patologie bilio-pancreatic cuprini n lotul studiat
Grupa de vrst

Prevalena procentual (%)

Rata de cretere

Raport

<20 ani (I)

0.79

20-39 ani (II)

17.92

22.67

II/I

40-59 ani (III)

34.26

1.91

III/II

60 ani (IV)

47.04

2.63

IV/III

Analiza statistic inferenial a repartiiei pacienilor cu urgene bilio-pancreatice din lotul studiat, a artat o
diferen slab semnificativ statistic referitoare la prevalena patologiei bilio-pancreatice acute pe grupe de vrst la
sexul masculin ntre mediul urban i cel rural (2, p < 0.015892). n ceea ce privete sexul feminin i respectiv
prevalena global la nivelul lotului de pacieni, s-au observat diferene semnificative statistic ntre mediul urban i
rural: la femei exist o predominan semnificativ statistic a patologiei n mediul urban (2, p < 0.000990); prevalena
global pe cele dou sexe n mediul urban este crescut semnificativ statistic fa de mediul rural (2, p < 0.000013).
Sublotul de pacieni cu dischinezie biliar
Examinarea ultrasonografic n primele 2 ore de la prezentarea n U.P.U. a evideniat prezena litiazei biliare la
numai 4% dintre pacienii cu dischinezie biliar, 58% prezentnd examinare ultrasonografic normal. Nu s-au
evideniat aspecte de urgene bilio-pancreatice care s necesite intervenie chirurgical n urgen.
Sublotul de pacieni cu tablou clinic de colic biliar
Examinarea ultrasonografic efectuat n primele 2 ore de la prezentarea n U.P.U. a evideniat prezena litiazei
la 85.96%, iar 6.32% dintre pacieni nu au prezentat modificri ultrasonografice. S-au evideniat complicaii ale litiazei
biliare la 56.22% dintre subieci. Cea mai frecvent complicaie a litiazei biliare evideniat ultrasonografic a fost
colecistita acut (34.66%).
Sublotul cu sindrom icteric
Evaluarea ultrasonografic n primele 2 ore de la prezentarea n urgen a pacienilor cu sindrom icteric nu a
evideniat modificri ultrasonografice la 13% dintre pacieni. S-a observat aspectul de icter obstructiv, cu dilatarea cii
biliare principale i a cilor biliare intrahepatice la 58% dintre pacienii din lot, 24% dintre acetia prezentnd o cauz
tumoral a obstruciei. Un alt aspect observat n cazul a 19% dintre pacienii cu sindrom icteric, care prezentaser
anamnestic i colic biliar, a fost acela de coledoc de pasaj, fr dilataii de ci biliare intrahepatice n condiiile
prezenei litiazei veziculare cu calculi sub 5 mm sau pn la 10 mm. Un procent important de pacieni (10%) au
prezentat litiaz coledocian n condiii de colecistectomie.
Sublotul cu tablou clinic de pancreatit acut
Evaluarea ultrasonografic n urgen nu a evideniat modificri ale lojei pancreatice la 34% dintre pacienii cu
tablou clinic de pancreatit acut. Aspectele ultrasonografice observate au ridicat suspiciunea de pancreatit acut prin
modificri de dimensiuni i ecostructur la 27% dintre pacieni. S-a decelat aspect ultrasonografic de pancreatit acut
sever, cu evidenierea de colecii la nivelul lojei pancreatice, peripancreatic i la distan la un procent de 29% dintre
pacieni, 4% dintre pacienii inclui n sublot prezentnd aspect de pseudochist imatur.
S-a analizat utiliznd testul Odd Ratio riscul de a prezenta modificri ultrasonografice la examinarea n urgen
i respectiv riscul de a avea o complicaie care s necesite intervenie chirurgical. S-a decelat un risc crescut pentru
pacienii avnd colic biliar de a prezenta o complicaie a litiazei (OR=19.1), evideniabil ultrasonografic, care s
necesite intervenie chirurgical (OR=109.32). Pacienii cu sindrom icteric prezint de asemenea risc crescut pentru o
complicaie care s necesite intervenie chirurgical n urgen (OR=22.38).
Analiza valorii metodei ultrasonografice n diagnosticul litiazei biliare i a complicaiilor acesteia s-a dovedit a
avea o sensibilitate de 91.35%, cu specificitate redus de 55.05%. Valoarea predictiv pozitiv a metodei a fost de
93.87%, cu o valoare predictiv negativ de 45.79%. Analiza valorii diagnostice a ultrasonografiei utiliznd Likelihood
ratio +(positive test result) de 2.03 i Likelihood ratio -(negative test result) de 0.17 a artat o putere bun a
metodei diagnostice n predicia pozitiv a patologiilor diagnosticate, cu un risc redus de subestimare ultrasonografic a
patologiilor existente.

Lotul B de pacieni
Lotul a inclus pacieni cu vrsta cuprins ntre 15 90 de ani, vrsta medie fiind 49.26 18.14 ani. Examinarea
ultrasonografic a pacienilor n primele 4 ore de la prezentarea n U.P.U. a documentat existena modificrilor
patologice de tip bilio-pancreatic cu potenial impact asupra simptomatologiei clinice la 25.98% dintre pacieni. La un
procent important de pacieni (36.31%) au fost diagnosticate ultrasonografic modificri patologice la nivelul tubului
digestiv care au explicat rezistena la terapia clasic antisecretorie administrat n urgen. S-a decelat de asemenea o
inciden crescut (17.32%) a modificrilor biliare diagnosticate ultrasonografic la pacienii cu sindrom dureros
epigastric.
S-a analizat statistic utiliznd testul Odd Ratio riscul de a exista o patologie bilio-pancreatic evideniabil
ultrasonografic n cadrul subloturilor de pacieni cu sindrom dureros epigastric i de hipocondru drept. S-a obinut un
OR de 1.53 (95% CI: 0.87 - 2.69) n cazul pacienilor cu sindrom dispeptic ulceros comparativ cu OR de 0.94 (95% CI:
0.24 - 3.60) n cazul pacienilor cu sindrom dureros de hipocondru drept. Analiza acestor date coroborate cu rezultatul
managementului terapeutic a artat c ultrasonografia n urgen evideniaz pacienii cu risc crescut de a necesita
intervenie chirurgical, OR=3.84 (95% CI: 0.47 31.16), din cadrul sublotului de pacieni cu sindrom dispeptic

ulceros.
Capitolul V: Ultrasonografia n urgenele biliare patologia colecistului - Studiul II
Studiul a fost de tip retrospectiv observaional evalund rolul ultrasonografiei la pacienii cu patologie litiazic
de vezicul biliar, simptomatic, care s-au prezentat n U.P.U. a Spitalului Clinic de Urgen O. Fodor.
V.3. Rezultate
Lotul examinat a cuprins un numr de 179 de pacieni cu vrsta medie de: 59.31 15.82 ani. La lotul de pacieni
diagnosticai ultrasonografic n urgen cu colecistit acut s-au analizat formele morfopatologice evideniate
postoperator i s-a observat un procent important (48%) de forme complicate de tip flegmonos i gangrenos.
Examinarea ultrasonografic n urgen ofer informaii despre modificrile parietale de tip ngroare parietal,
aspectul inflamator de dublu contur i pericolecistit sau prezena coleciilor pericolecistice. S-a observat c ngroarea
parietal este cea mai frecvent modificare observat la lotul de pacieni cu colecistit acut examinat n studiu (Tabelul
XXXVI). Un alt element analizat a fost concordana ntre aprecierea ultrasonografic a mrimii calculilor de la nivelul
veziculei biliare i dimensiunea msurat postoperator. S-a obinut o bun corelaie a dimensiunilor msurate prin cele
dou metode (40.24%), existnd ns i un procent nsemnat de subapreciere ultrasonografic a dimensiunilor calculilor
(29.89%). Este important de observat, din punct de vedere al practicii medicale, procentul redus de pacieni fr litiaz,
cu modificri parietale de tip colecistit, la care ultrasonografic s-a apreciat existena microlitiazei (1.22%).
Analiza semnificaiei statistice utiliznd Risk Ratio(RR) i Odd test(OR) a artat un risc crescut pentru
pacienii cunoscui cu litiaz biliar de a dezvolta forma cataral (RR=1.19; OR=1.32, 95% CI 0.71 - 2.44) i respectiv
forma cronic de colecistit (RR=1.53; OR=1.66 95% CI 0.72 3.79). Sublotul de pacieni necunoscui litiazici pn la
prezentarea n U.P.U. pentru episodul acut au risc mai crescut de a dezvolta colecistit form flegmonoas/gangrenoas
(RR=1.32; OR=1.69 95% CI 0.93 3.09). S-a evaluat aportul metodei ultrasonografice n urgen n ceea ce privete
diagnosticul litiazei biliare i a complicaiei de tip colecistit acut.
Pentru diagnosticul litiazei biliare n context de colecistit acut s-a obinut o sensibilitate a metodei de 100%,
specificitate de 98.7%, VPP de 98.7%, VPN de 100%, cu o acuratee a metodei de 93.39%. Valoarea LR + a fost de
76.9 evideniind o probabilitate mare de a exista litiaza biliar dac ultrasonografia a fost pozitiv. n cazul
diagnosticului formelor acute de colecistit s-a demonstrat o sensibilitate de 89.99%, cu specificitate de 84.44%, VPP
de 88.31%, VPN de 86.09%, cu o acuratee a metodei de 87.35%. Originalitatea studiului actual rezid din corelarea
aspectelor clinice i ultrasonografice cu cele intraoperatorii i analiza metodei ultrasonografice n diagnosticul
diferitelor forme morfopatologice de colecistit acut litiazic.
Tabelul XXXVI. Incidena procentual a modificrilor parietale observate ultrasonografic la nivelul colecistului
raportat la numrul total de pacieni cu colecistit
Colecistita
cataral

Colecistita
flegmonoas

Colecistita
gangrenoas

Colecistita
cronic

grosime perete >4 mm

20.89

18.99

20.89

10.76

dublu contur

13.29

16.46

20.25

5.70

pericolecistit

3.16

8.23

9.49

0.63

colecii pericolecistice

1.27

1.90

3.80

0.00

Modificri ecografice (%)

Capitolul VI: Ultrasonografia n afeciuni acute ale cilor biliare - Studiul III
Studiul a fost de tip prospectiv, evalund rolul ultrasonografiei la pacienii cu tablou clinic de icter obstructiv,
care s-au prezentat n U.P.U. a Spitalului Clinic de Urgen O. Fodor, n perioada februarie 2005 martie 2005.
VI.3.Rezultate
Lotul a cuprins un numr de 31 de pacieni (16 femei i 15 brbai) cu icter obstructiv diagnosticai n urgen, cu
vrsta cuprins ntre 29 89 de ani, avnd vrsta medie de 58.06 13.76 ani, respectiv 55.56 14.60 ani la femei i
60.73 12.75 ani la brbai.
Examenul ultrasonografic n urgen a vizualizat dilataiile de ci biliare datorate obstruciei, dar nu a putut
preciza etiologia obstruciei la 41.93% dintre pacieni. Analiza comparativ a diagnosticului etiologic al obstruciei
suspicionat ultrasonografic, cu diagnosticul endoscopic evideniat la colecistopancreatografie retrograd endoscopic, a
artat o diferen slab semnificativ statistic n sensul corelaiei pozitive a investigaiilor (MW, p=0.02659). Nu s-au
observat diferene semnificative statistic n aprecierea dimensiunii cii biliare principale efectuat ultrasonografic i prin
colecistopancreatografie retrograd endoscopic (MW, p=0.832748). S-a demonstrat astfel c ultrasonografia este util
n urgen n aprecierea dimensiunii cilor biliare i poate fi utilizat pentru evaluarea n dinamic a acestora. Referitor
la diagnosticul litiazei de cale biliar ultrasonografia a permis vizualizarea la 32.25% dintre pacieni,
colecistopancreatografia retrograd endoscopic confirmnd-o la 48.38% dintre pacieni.
S-a analizat valoarea ultrasonografiei n urgen pentru diagnosticul litiazei obstructive de cale biliar,
obinndu-se o sensibilitate de 66.66%, cu specificitate de 51.61% i acuratee diagnostic de 56.6%. Valoarea
predictiv pozitiv a fost de 40%, iar valoarea predictiv negativ de 76.19%, cu o Likehood ratio + de 1.32,
Likehood ratio - de 0.64.
Capitolul VII: Ultrasonografia n pancreatita acut - Studiul IV
Studiul de fa i propune analizarea aportului ultrasonografiei efectuate n urgen n evaluarea pacienilor cu
suspiciune clinic de pancreatit acut i triajul celor cu pancreatit form sever.
Studiul a fost de tip retrospectiv observaional evalund rolul ultrasonografiei n diagnosticul bolii i a
complicaiilor la pacienii cu pancreatit acut care s-au prezentat n U.P.U. a Spitalului Clinic de Urgen O. Fodor, n
perioada august 2004 decembrie 2006.
VII.3. Rezultate
Lotul a cuprins un numr de 95 de pacieni cu pancreatit acut, cu vrsta cuprins ntre 23 i 85 de ani, avnd
vrsta medie de 50.55 14.20 ani, predominant de sex masculin, cu un raport B/F=1.96.
Analiza etiologiei pancreatitei acute la lotul studiat a evideniat predominana cauzei etanolice la 42.11% dintre
pacieni. Cele dou etiologii frecvent incriminate, etanolul i litiaza biliar au fost prezente la 75.8% dintre pacieni, la
6.32% neputndu-se preciza cauza. S-a evideniat c n primele 6 ore de la debutul bolii acceseaz serviciile de urgen
cel mai frecvent pacienii din grupa de vrst 40 59 de ani (10.87%).
Evaluarea imagistic de tip ultrasonografic efectuat n urgen a putut analiza loja pancreatic la 85.6% dintre
pacienii cu pancreatit acut, la 76.84% dintre acetia existnd modificri de ecostructur i ecogenitate. La 14.74%
dintre pacienii cu pancreatit acut nu s-a putut evalua loja pancreatic din lips de fereastr acustic.
Analiznd severitatea pancreatitei acute apreciat prin scoruri de severitate, aspectele ultrasonografice i de
dinamic a valorilor parametrilor biochimici, s-a evaluat semnificaia statistic a elementelor componente din scorurile
de severitate (BISAP, HAPS, Ranson, SIRS) i a modificrilor ultrasonografice de tip colecii. S-a demonstrat la lotul
de 95 de pacieni cu pancreatit acut c parametrii cu nalt semnificaie statistic pentru forma sever de pancreatit
sunt (test Fischer, p=0.0000): prezena a mai mult de 2 colecii la examinarea ultrasonografic n urgen, respiraia >
20/min, febra > 38C, SIRS pozitiv, colecia pleural la examinarea ultrasonografic, leucocitoza > 16000/mm3, ASAT
> 250 UI/l. Se propune astfel un nou scor de triaj clinico-biochimico-ultrasonografic n urgen (STCBUS) a pacienilor
cu forme severe de pancreatit, care trebuie orientai spre servicii specializate de terapie gastroenterologic:
Parametrii clinici: 1.respiraia > 20/min 1 punct; 2.febra > 38C - 1 punct; 3.SIRS pozitiv 1 punct;
Parametrii ultrasonografici: 4.prezena a mai mult de 2 colecii la examinarea ultrasonografic 1 punct;
5.colecia pleural la examinarea ultrasonografic - 1 punct;
Parametrii biochimici: 6.leucocitoza > 16000/mm3 - 1 punct; 7.ASAT > 250 UI/l - 1 punct

Se consider indicat terapia specific gastroenterologic n condiiile prezenei a trei parametri, cte unul din
fiecare categorie (clinic, ultrasonografic i biochimic) sau asocierea parametrilor ultrasonografici cu un parametru
clinic. Scorul propus necesit validare pe un numr mai mare de pacieni sau evidene suport pentru demonstrarea
existenei necrozei pancreatice, accesibile n urgen.
Capitolul VIII: Ultrasonografia cu contrast n pancreatita acut - Studiul V
Studiul referitor la rolul ultrasonografiei cu contrast n evaluarea severitii pancreatitei acute a fost de tip
prospectiv i a cuprins un numr de 25 de pacieni, care s-au prezentat n Compartimentul de Urgen al Spitalului
Clinic de Urgen O. Fodor din Cluj Napoca n perioada decembrie 2008 iulie 2010, selectai pe baza tabloului
clinic, a confirmrii biochimice a pancreatitei acute i a examinrii ultrasonografice n modul B.
VIII.3. Rezultate
Analiza descriptiv a lotului de 25 pacieni selectai pentru examinarea ultrasonografic cu contrast a evideniat
o vrst medie de 46.16 13.99 ani. Caracteristicile evolutive la subiecii din lotul studiat au artat prezena la 12%
dintre pacieni a fenomenelor de insuficien multipl de organ (MSOF). S-au evideniat complicaii la 32% dintre
subieci. Analiza parametrilor biochimici semnificativi pentru procesul necrotico-inflamator pancreatic n urgen i n
dinamic a artat prezena leucocitozei la 80% dintre pacieni, 44% avnd valori peste 16000/mm3, cu o valoare medie
de 15006.4 7122.07/mm3. Proteina C reactiv (PCR) evaluat la 48 de ore de la internare a avut o valoare medie
crescut (10.34 8.98 mg/dl).
Examinarea ultrasonografic transabdominal a evideniat la 100% dintre pacienii cu pancreatit acut
selectai n studiu, modificarea lojei pancreatice sub aspectul ecostructurii i al ecogenitii, la 8% dintre acetia
vizualizndu-se delimitarea capsular a parenchimului, iar 92% prezentnd contur slab delimitat. S-a evideniat prezena
la 64% dintre pacieni a coleciilor cu diferite localizri, 28% prezentnd colecii la nivelul lojei pancreatice i respectiv
56% n regiunile adiacente lojei pancreatice . Aspectele calitative observate la examinarea ultrasonografic cu agent de
contrast au evideniat aspectul de pancreatit acut necrotico-hemoragic la 76% dintre pacieni. La 12% dintre subieci
semnalul acustic dup administrarea de contrast a prezentat o ntrziere n apariie, cu moderat reducere a intensitii
acustice. Examinarea a permis identificarea capsulei pancreatice la 20% dintre pacieni, iar la 64% s-au observat aspecte
de tip inflamator la nivelul parenchimului pancreatic. Ultrasonografia cu contrast a permis identificarea de noi colecii
la 20% dintre subieci, preciznd aspectul de fuzeu la 56% din pacienii selectai n studiu.
Analiza valorii medii a gradientului maxim atins n primele 40 de secunde post administrare de agent de
contrast a artat o valoare medie maxim la nivelul AMS de 19.37 8.53 dB. S-a evideniat prezena n ariile de
inflamaie a unui semnal acustic cu valoarea medie a intensitii acustice uor redus (14.76 6.70 dB) comparativ cu
valoarea de la nivelul AMS. n ceea ce privete ariile de necroz valoarea medie a gradientului (8.97 9.28 dB) a fost
mult redus comparativ cu cea nregistrat n AMS, aspect observat i n ariile hipovasculare la nivelul crora
gradientele au prezentat valori intermediare ntre necroz i inflamaie. Analiza statistic a valorilor gradientelor
maxime n AMS i ariile pancreatice de tip inflamaie, necroz i hipovasculare a artat modificri semnificative
statistic (KW, p=0.0008), cu probabilitate semnificativ statistic de variaie (test F, p=0.001). Acestea pot reprezenta
evidene ultrasonografice practice pentru diferenierea gradului de necroz pancreatic sau a amplitudinii fenomenului
inflamator.
S-a analizat valoarea timpului mediu de atingere a gradientului maxim n primele 40 de secunde dup
administrarea substanei de contrast ultrasonografice. S-a observat c nu exist diferene semnificative statistic ntre
valoarea medie n AMS (15.85 4.60 sec.) i ariile de inflamaie (15.15 3.20 sec.), la ambele categorii existnd o
deviaie standard redus, ceea ce confirm omogenitatea n distribuie a valorilor. La nivelul ariilor de necroz s-a
evideniat un timp mediu de atingere a gradientului maxim semnificativ crescut: 22.69 7.55 sec fa de martorul AMS.
Analiza statistic a timpului de atingere a gradientului maxim n AMS i n ariile pancreatice de tip inflamaie,
necroz sau hipovasculare a evideniat diferene semnificative statistic (KW, p=0.0006), cu grad mare de probabilitate
de a avea aceeai variaie (test F, p=0.00004). Acest aspect este concordant cu cel al analizei statistice a valorii
gradientului maxim post administrare de contrast ultrasonografic n arii similare de ecostructur parenchimal care sunt
modificate n context de pancreatit acut.
Analiza valorii AC de tip wash in n primele 40 sec. a evideniat diferene nesemnificative statistic ntre
AMS i zonele de inflamaie (KW, p=0.0802). Observndu-se comparativ valorile de la nivelul AMS cu valorile
obinute din regiunea de interes (RI) poziionat n aria celor 3 tipuri de modificri structurale observate ultrasonografic
n pancreatita acut s-au evideniat diferene slab semnificative statistic (KW, p=0.0115). Se observ creterea valorii
AC odat cu gradul de necroz, fenomen concordant cu prelungirea timpului de atingere a gradientului maxim.

S-a efectuat analiza comparativ a variaiei AC de tip wash out n intervalul 40 - 80 sec. dup administrare
de contrast, observndu-se diferene semnificative statistic (KW, p=000.8) ntre diferitele zone modificate ecostructural
n pancreatita acut comparativ cu martorul AMS. S-a observat n plus i un fenomen nedescris nc literatur, acela de
wash in ntrziat, cu nou vrf de intensitate acustic n intervalul 60 100 sec., n 72% din cazuri acesta fiind prezent
la 80 de sec. Se observ o concordan de 60% n ceea ce privete procentul de necroz evaluat prin metoda
ultrasonografic i cea computer tomografic.
S-au efectuat corelaii ntre evaluarea procentual a ariei de necroz observate US i numrul de colecii
diagnosticate US, observndu-se o corelaie pozitiv moderat semnificativ statistic (S, p=0.0009), ceea ce denot
paralelismul ntre creterea gradului de necroz pancreatic i numrul de colecii. Se observ o corelaie pozitiv nalt
semnificativ statistic ntre severitatea evoluiei i numrul total de colecii (p=0.00001), aspectul de fuzeu (p=0.00001)
i respectiv prezena coleciilor pleurale (p=0.00001).
Analiza metodei ultrasonografice n diagnosticul pancreatitei acute necrotico-hemoragice a evideniat o sensibilitate de
76%, specificitate de 100%, cu acuratee de 100%.
S-a evideniat n studiul nostru un aspect particular de vascularizaie tardiv n ariile cu polimorfism lezional
i periarii necrotice, fenomen cu implicaii practice n evaluarea zonelor de parenchim restant i a tulburrilor
circulatorii locale induse de SIRS. Acest fenomen nu a fost descris n literatura de specialitate.S-a observat c zonele
hipoecogene reprezint frecvent arii de necroz complet sau parial, asociate cu arii de parenchim restant, unele cu
aspect inflamator. Aceste observaii ultrasonografice calitative subliniaz aportul examinrii cu contrast n triajul
pacienilor cu forme severe de pancreatit acut.
Propunere pentru scor de triaj n urgen a formei sever de pancreatit acut, clinic-biochimicultrasonografic complex (STCBUSC):
Parametrii clinici: 1. respiraia > 20/min 1 punct; 2. febra > 38C - 1 punct; 3. SIRS pozitiv 1 punct;
Parametrii ultrasonografici: 4. prezena a mai mult de 2 colecii la examinarea ultrasonografic 1 punct; 5. colecia
pleural la examinarea ultrasonografic - 1 punct;
Parametrii ultrasonografici examinare CEUS: 6. necroz pancreatic 1-3 puncte (analogie cu CT: <30% - 1pct.;
30-50% - 2 pct.; >50% - 3pct.); 7. fuzee peripancreatice i la distan 1punct;
Parametrii biochimici: 6. leucocitoza > 16000/mm3 - 1 punct; 7. ASAT > 250 UI/l - 1 punct;
Pentru triajul corect al formelor severe de pancreatit acut care necesit trimiterea ntr-un serviciu specializat
de terapie intensiv gastroenterologic este necesar documentarea prezenei necrozei pancreatice evideniat prin
CEUS, asociat cu ali trei parametri, obligator cu cel puin un parametru biologic i unul clinic care s ateste faza acut
a modificrilor pancreatice. Scorul minim pentru ndrumarea pacientului n terapie intensiv gastroenterologic este 4.
Acest scor necesit validare i eventual optimizarea valorii cut-off pe un numr mai mare de pacieni.
Capitolul X: Concluzii finale i contribuii personale

Studiile prezentate n lucrarea de fa constituie prima comunicare statistic, la nivel naional, asupra evalurii
rolului accesului permanent la examinarea ultrasonografic n urgen, cu scopul de a-i analiza aportul diagnostic,
prognostic i de utilizare n protocoalele de triaj a urgenelor bilio-pancreatice.
1. Analiza descriptiv a datelor epidemiologice la loturile de pacieni studiate a evideniat aspecte de asisten
primar care necesit ameliorare:
Incidena crescut a urgenelor biliare la subiecii de sex feminin i din mediul urban.
Incidena crescut a pancreatitei acute la subiecii de sex masculin i din mediul urban.
Incidena crescut a tulburrilor funcionale de tip dischinezie biliar la sexul feminin i n mediul urban.
Proveniena predominant a pacienilor cuprini n studii din mediul urban, aspect care ridic problema
factorilor de risc sau a accesibilitii reduse la serviciile de urgen a subiecilor din mediu rural.
Adresabilitatea tardiv a pacienilor ctre serviciile de urgen, reprezint o problem de asisten medical
primar i de educaie sanitar.
Compliana sczut a pacienilor la terapia chirurgical, n special pentru cei provenii din mediul rural a pus n
discuie existena carenelor de educaie sanitar.
Evidenierea unui procent important de 55.11% dintre subiecii cu aspect ultrasonografic de colecistit acut
litiazic ca nefiind cunoscui anterior cu litiaz biliar, relev absena screeningului populaional la nivel de
medicin primar.

2. Analiza statistic a performanei metodei ultrasonografice n U.P.U. a demonstrat c este un test diagnostic facil
i absolut necesar n asistarea urgenelor bilio-pancreatice:
Studiul I: Urgene bilio-pancreatice
a. Detectarea litiazei biliare sensibilitate 91.35%, LR- 0.17;
b. Evidenierea riscului de urgen cu indicaie chirurgical: OR=109.32 la sublotul de pacieni avnd
colic biliar;
c. Aprecierea riscului de complicaii pancreatice ale litiazei biliare: OR=3.4 n cazul decelrii de calculi
sub 10 mm la nivelul vezicii biliare;
Studiul II: Colecistite acute
a. Detectarea litiazei biliare sensibilitate de 100%, acuratee diagnostic de 93.39%, LR+ 76.9;
b. Detectarea formei acute de colecistit specificitate de 84.44%, VPN de 86.09%, acuratee
diagnostic de 87.35%;
c. Studiul III: Patologie acut de cale biliar
d. Diagnosticul obstruciei sensibilitate de 100%;
e. Diagnosticul cauzei litiazice a obstruciei sensibilitate de 66.66%, VPN de 79.19%;
Studiul V: Pancreatit acut examinare CEUS
a. Detectarea pancreatitei acute form sever (necrotic): sensibilitate 76%, acuratee diagnostic
100%.
3. Analiza corelaiei simptomatologiei clinice cu rezultatul examinrii ultrasonografice a demonstrat rolul
ultrasonografiei n decelarea complicaiilor litiazei biliare n condiiile prezentrii cu tablou clinic frust de sindrom
dureros de etaj abdominal superior.
4. Corelarea aspectelor ultrasonografice cu cele evideniate la examinarea colangio-pancreatografic a
evideniat utilitatea metodei n monitorizarea dinamicii dimensiunilor cilor biliare n condiii de obstrucie acut i
dup terapie intervenional.
5. Corelarea datelor clinice, biochimice i ultrasonografice cu severitatea pancreatitei acute, apreciat i prin
numrul de zile de spitalizare, a permis selectarea parametrilor care caracterizeaz un nou scor de severitate n
pancreatita acut.
Valoarea practic a lucrrii posibiliti de implementare
6. S-au evideniat factori de risc epidemiologici (vrsta peste 50 de ani, mediul rural i sexul feminin) i
ultrasonografici (calculi sub 10 mm, aspectul de coledoc de pasaj) ai complicaiilor litiazei biliare n arealul geografic
studiat.
7. S-a propus un protocol standardizat bazat pe evidene practice de abordare a urgenelor bilio-pancreatice n
U.P.U., adaptat sistemului sanitar, care amelioreazeaz triajul pacienilor chirurgicali i optimizeaz abordarea
diagnostico-terapeutic.
8. S-a propus un scor de triaj clinico-biochimic-ultrasonografic de severitate a pancreatitei acute, bazat pe
evidene practice, utiliznd parametri facil de evaluat, care se pot determina n U.P.U.: respiraia>20/min., febra >38oC,
SIRS pozitiv, leucocitoz >16000/mm3, ASAT>250U/l, prezena a mai mult de 2 colecii la examinarea
ultrasonografic, evidenierea coleciei pleurale la examinarea ultrasonografic.
9. Introducerea examinrii ultrasonografice cu contrast n pancreatitele acute a dovedit creterea acurateei
diagnostice a formelor severe, necrotice i optimizeaz scorul clinico-biochimico-ultrasonografic de triaj a formelor
severe, care necesit asistare n terapie intensiv specializat gastroenterologic.
10. Analiza cantitativ a parametrilor dinamici de tranzitare, de ctre substana de contrast ultrasonografic, a
ariilor parenchimale de tip inflamator, necrotic, hipovascular sau cu vascularizaie tardiv permite identificarea
parenchimului pancreatic restant.
11. Analiza CEUS creeaz premisa dezvoltrii studiilor de tip reologic i analiz matriceal a modificrilor
vasculare locale i la distan n condiii de inflamaie pancreatic acut, cu impact terapeutic i prognostic.
Aport n decizia medical
12. Explorarea imagistic ultrasonografic n modul B i cu substan de contrast, prin diagnosticul
modificrilor morfologice secundare prezenei litiazei sau a aciunii altor factori etiologici asupra parenchimului
pancreatic i veziculei biliare, reprezint un factor de diagnostic precoce i screening al complicaiilor bilio-pancreatice,
cu abordare terapeutic adecvat bazat pe evidene.

CURRICULUM VITAE
1. Nume: GOLEA
2. Prenume: ADELA
3. Data i locul naterii: 28.10.1970, DROBETA-TURNU-SEVERIN, MEHEDINTI
4. Cetenie: ROMN
5. Stare civil: NECSTORIT
6. Studii:
Instituia
Universitatea de Medicin i Farmacie
Liceul Sanitar
Iuliu Haieganu
Drobeta Turnu Severin
Universitatea Babe Bolyai
Cluj-Napoca
Perioada: de la (luna, anul)
Sept. 1989-iulie 1995
Sept.1985 iulie 1989
pn la (luna, anul)
Febr.-iulie. 1997
Grade sau diplome obinute
Doctor - medic
Sor medical
Pedagogie pentru cadre didactice

Liceul Pedagogic- profil

desen,
Drobeta Turnu Severin

7. Experiena profesional:
Perioada: Ian. 1996Apr. 1999mar. 1999
iul. 1999

Aug. 1999-mai 2008

Mai 2008prezent

Septembrie 2007- prezent

Locul:

Cluj-Napoca

Cluj-Napoca

Cluj-Napoca

Cluj-Napoca

Instituia:

Spitalul
Judeean

Spitalul Clinic de Aduli

UPU
Centrul de Formare n US

Spitalul Clinic
Judeean de
Urgen, UPUSMURD

UMF Iuliu Haieganu

Catedra de Medicin de
Urgen

Funcia:

Medic
rezident
Medicin de
Urgen

Drobeta-Tr.Severin
Spitalul
Judeean
UPU
Medic
specialist
Medicin de
Urgen

Sept. 1977 iulie 1985

Medic specialist/primar (2004)

Medic pimar
Asistent universitar
Competen n ecografie general
Management
asociat (sept. 2007)
Competen n managementul
de proiect
ef de lucrri (martie
serviciilor de sntate
Colaborare cu
2009)
Formare n US, urgen
UMF Cluj
Proiecte didactice/cercetare
8. Doctorat: Catedra de Imagistic, nmatriculat la 01.11.2004, conductor tiinific prof. Dr. Radu Badea, cu
titlul: Corelaii clinico-imagistice n scopul stabilirii unei conduite terapeutice optimale n urgenele bilio-pancreatice.
9. Locul de munc actual i funcia: Universitatea de Medicin i Farmacie Iuliu Haieganu ef de
lucrri, Unitatea de Primiri Urgene, Spitalul Clinic Judeean de Urgen Cluj Napoca - medic primar
10. Membru al asociaiilor profesionale: membru n Societatea Romn de Urgen i Catastrof din
Romnia(SMUCR) din 1997, vicepreedinte SMUCR filiala Cluj din 2002-2008; membru n European Society for
Emergency Medicine(EUSEM) din 2008; membru n Societatea Romn de Ultrasonografie n Medicin i
Biologie(SRUMB) din 2001; membru n European Federation of Societies for Ultrasound in Medicine and Biology(
EFSUMB) din 2002; membru American Asociation for the Advancement of Science n 2003; Colegiul medicilor
12. Limbi strine cunoscute: englez-nivel mediu, francez-nivel nceptor
13.Alte competene: ecografie intervenional, ecografie cardiac, urgene pediatrice, radiopatologieintervenie medical n situaii de urgen radiologic sau accidente nucleare, electrocardiografie clinic, medicin de
catastrof
14. Premii acordate drept recunoatere a rezultatelor activitii profesionale / tiinifice: Mai 2003 Premiul
Societii Romne de Ultrasonografie n Medicin i Biologie pentru poster, la Conferina Naional de Ecografie,
Constana; Decembrie 2007 Premiul pentru suportul acordat Programului REMSSy IV n perioada 2003-2007; Iunie
2008 Premiul Gheorghe Jovin, mpreun cu colectivul CECUS UMF Cluj, EUROSON, Timioara, Romnia
17. Participri la manifestri tiinifice: comunicri orale/postere la manifestri naionale 20; comunicri
orale/postere manifestri internaionale: 11
18. Cursuri postuniversitare urmate n ar i strintate: 35
19. Lector la cursuri postuniversitare n cadrul unor conferine: 11.04. 12.04.2007: Primul curs internaional
de ultrasonografie n practica de anestezie i terapie intensiv, Cluj Napoca; 28.06.2007: Tehnici de ecografie n
medicina de urgen, Conferina Naional a Societii de Medicin de Urgen i Catastrof din Romnia, Iai; 02.12.05.12.2007: Ultrasound in Emergency and Critical Care Medicine, Timioara; 15.06.2008: Curs practic de
ultrasonografie pentru anesteziti, Reuniunea anestezitilor Romni i Germani la Cluj Napoca; 21 aprilie 2009: Cursul
de implementare a Ghidului de diagnostic i tratament al infarctului miocardic cu supradenivelare de segment ST, Cluj
Napoca

10

20. Cri de specialitate publicate: Editori coordonatori R. Badea, S. Dudea, T. Suteu, A. Golea,
ECOGRAFIE N URGENE MEDICO-CHIRURGICALE: I. FAST. II. ECOGRAFIE DE URGENTA, editura Alpha,
2006, editat n cadrul Programului de Reablitare a Sistemului de Urgen REMSSY, etapa IV, ISBN (10) 9737871-45-9, cod CNCSIS 285
21. Capitole publicate n volume colective:
I. Adela Golea, Titus uteu, Radu I. Badea, Cap.26 Explorarea ecografic n evaluarea urgenelor vitale i a strilor
critice. Tehnica FAST n Tratat de ultrasonografie clinic, vol.III Aparat locomotor, ecografie pediatric, ecografie
intervenional, progrese i concepte noi n ultrasonografie, ed. Medical Bucureti, pg. 686-695, 2008
II. Horea tefnescu, Adela Golea, Radu I. Badea, Cap.28 Soluii de telemedicin i e-health aplicate n
ultrasonografie n Tratat de ultrasonografie clinic, vol.III Aparat locomotor, ecografie pediatric, ecografie
intervenional, progrese i concepte noi n ultrasonografie, ed. Medical Bucureti, pg. 705-713, 2008
III.Ioan Stoian, Radu Badea, colectivul de elaborare: SC IPA SA, UMF Iuliu Haieganu Cluj Napoca Centrul de
Formare n Ultrasonografie (P. Mircea, S. Dudea, Adela Golea, Carolina Botar Jid, T. Vasile, T. uteu), Institutul
Clinic de Urologie i Transplant Cluj, UMF Trgu Mure, Sistem cooperativ aplicat n medicina de urgen i
catastrof, Ed. Digital Data Cluj 2008, ISBN 978-973-7768-46-9
22.Articole publicate n extenso n reviste indexate n baze de date internaionale:
I. Adela Golea, Radu Badea, Mihai Socaciu, Brndua Diaconu, Daniela Iacob. Quantitative analysis of tissue perfusion
using contrast-enhanced transabdominal ultrasound (CEUS) in the evaluation of the severity of acute pancreatitis.
Medical Ultrasonography 2010, 12(3): 198-204
II. Clin Mitre, Adela Golea, Iurie Acalovschi, Teodora Mocanu, Ana Maria Caea. Ultrasound-guided external jugular
vein cannulation for central venous acces by inexperienced trainees. Eur J Anaesthesiology 2010; 27:300-303
III. Adela Golea, Radu Badea, Titus uteu, Lidia Ciobanu, Teodora Surdea-Blaga. The contribution of
ultrasonography to the diagnostic-therapeutic triage of the bilio-pancreatic emergency. Medical Ultrasonography 2009,
11(3): 41-49
IV. A. Golea, Radu Badea, Mihail Socaciu. Processing of wash-in/wash-out curves and signal intensity ultrasound in
contrast enhancement ultrasound support for new computer models for optimizing the diagnosis and therapeutic
management of acute pancreatitis. IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2010 (THETA 17). pg.258-262
V. D. Capatina, O. Dancea, R. Cazan, A. Golea, C. Boeriu, A. Stoian, Using the cooperative robots concept in
emergency and catastrophes medicine, IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2008 (THETA 16), IEEE Catalog number CFP08AQT-PRT, pg. 134-138 (IEEE/ISI covered, IEEE
Explore indexed), ISBN 978-1-4244-2576-1
VI. I.Stoian, A. Golea, R. Badea, A. Moldovan, O. Dancea, C. Posteuca, Using the cooperative robots concept in
emergency and catastrophes medicine, IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2006 (THETA 15), IEEE Catalog number 06EX1370, pg. 415-419 (IEEE/ISI covered, IEEE Explore
indexed), ISBN 1-4244-0360-X
23.Articole publicate n extenso n reviste de circulaie naional recunoscute:
I.T. uteu, R. Badea, Adela Golea, Monica Lupor Morgovan, Aportul diagnostic al ultrasonografiei n evaluarea
sindromului dureros acut epigastric, Revista Romn de Ultrasonografie, Vol.8, nr.4,pg.219-227, 2006, ISSN 14545829, CNCSIS 126 categoria D
II.Adela Golea, T. uteu, H. Branda, T.Vasile, R. Badea, Aportul diagnostic al ultrasonografiei n evaluarea patologiei
hepatice posttraumatice. Importana problemei ilustrat n imagini, Revista Romn de Ultrasonografie, Vol.8, nr.12,pg.21-27, 2006, ISSN 1454-5829, CNCSIS 126 categoria D
III.Diana Dumitracu, M. Varga, A. Nicolaenco, C. Bodolea, C. Zdrehus, E. Kallo, G. Pit, A. Golea, oc anafilactic
fatal la Penicilin: prezentarea unui caz i date din literatur, Clujul Medical, vol.LXXIV, nr.1-2, ISSN 1222-2119,
pg.136-140, 2000, CNCSIS 253 categoria B
24.Articole publicate in extenso n volumele unor manifestri naionale:
I.Adela Golea, Radu Badea, Monitorizarea ultrasonografic n pancreatita acut, Jurnalul Roman de Anestezie si
Terapie Intensiv, vol.15, suppl.2, 2008, ISSN 1582-652X, pg. 36-40, CNCSIS 203 categoria B+
II.Adela Golea, Ultrasonografia n urgen Tehnica FAST, Revista Romn de Ultrasonografie, Vol.9, Supl.1,
pg.133-135, 2007, ISSN 1454-5829, CNCSIS 126 categoria D
25.Compact discuri, alte materiale didactice:
I.Adela Golea. Program e-learning: http://www.e-sanatatepublica.ro/index.php/Cont: ECOGRAFIE N URGENE
MEDICO-CHIRURGICALE. PARTEA I. NOIUNI GENERALE DE ECOGRAFIE FAST, editat n cadrul
Programului de Reablitare a Sistemului de Urgen REMSSY, etapa IV, 2007
II.Autori: medical: dr.Adela Golea, tehnic: fiz. Clin Cpraru; Colaboratori medicali: prof. dr.R. Badea, dr. T. uteu,
conf. dr. A. Costache, ef de lucr.Dana Elena Nedelcu, asist. univ. dr. Irina Jari, CD: Ecografie de Urgen - FAST,
editat n cadrul Programului de Reablitare a Sistemului de Urgen REMSSY, etapa IV, Centrul de Educaie i
Cercetare n Ultrasonografie al Universitii de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca, Centrul pentru
Politici i Servicii de Sntate (CPSS) Bucureti, 2006, ISBN (13)978-973-7871-46-6
III.T. uteu, A. Golea, CD: Aplicaii ale ecografiei n urgenele abdominale, imagini commentate: Centrul de Formare
n Ultrasonografie, Ed. Universitii de Medicin i Farmacie Cluj-Napoca, 2004, ISBN 973-693-049-1, cod CNCSIS
146

11

26.Experien n proiecte i programe de cecetare i formare profesional

Programul/Proiectul

Funcia n proiect

Perioada:

1.SonoDig: Program Idei CNCSIS: 833/2008

cercettor

2. SIMTECH: Cnmp parteneriate 4446/2008

cercettor

Contractare
2009 -2010
1/10/2008
30/09/2011
2007 - 2009

3. Implementarea anesteziei intravenoase totale cercettor

CNCSIS:2193/09.2007
4.REMSSy IV Program romno-elveian:
Lector; Coordonator sub- 2006 - 2007
program Ecografia de urgen
FAST
5.COOPURG: Sistem telematic cu unitati de Responsabil tiinific
15.10.2005
interventie mobile cooperative aplicat in medicina
30.06.2008
de urgenta si catastrofa CoopUrg, CEEX: 4/2005
6.Programul Matra-KAP

Administrator baze de date

7.REMSSy
III
Program
romno-elveian Lector program instruire
(Reabilitarea Sistemului Serviciilor de Asisten
Medical de Urgen din Romnia)

12

01.09.200431.12.2006
2004 - 2005

Starea
actual
ian. derulare
- derulare
derulare
ncheiat

- ncheiat

ncheiat
ncheiat

Doctoral Thesis Abstract

CLINICAL AND IMAGING CORRELATIONS WITH THE PURPOSE OF ESTABLISHING THE
OPTIMAL THERAPY CONDUCT IN BILIO-PANCREATIC EMERGENCIES
Ph.D. COORDINATOR: PROF. DR. RADU BADEA
Ph.D. CANDIDATE: ADELA GOLEA
Cluj Napoca 2010
KEY WORDS: ultrasonography, biliopancreatic emergency, acute pancreatitis, clinical-imaging correlations,
examination of choice, acute cholecystitis, acute biliary tract disease, diagnostic algorithm, contrast enhanced
ultrasonography
TABLE OF CONTENTS
INTRODUCTION ____________________________________________________________________________________________________ 4
PART ONE. PRESENT LEVEL OF KNOWLEDGE _______________________________________________________________________ 5
CHAPTER I. BILIOPANCREATIC EMERGENCIES ______________________________________________________________________ 6
I.1. NOSOLOGY _____________________________________________________________________________________________________ 6
I.1.1. Defining biliopancreatic emergencies _____________________________________________________________________ 6
I.1.2. Integration with surgical emergencies ____________________________________________________________________ 8
I.2. INCIDENCE _________________________________________________________________________________________________ 9
I.3. EPIDEMIOLOGY DATA _______________________________________________________________________________________ 11
I.3.1. Biliary lithiasis _____________________________________________________________________________________ 11
I.3.2. Acute pancreatitis ___________________________________________________________________________________ 12
I.4. PATHOGENESIS _____________________________________________________________________________________________ 14
I.4.1. Biliary lithiasis pathogenesis __________________________________________________________________________ 14
I.4.2. Pathogenesis of biliary lithiasis complications _____________________________________________________________ 16
I.5. HUMAN RESOURCES, MATERIALS AND INFRASTRUCTURE ____________________________________________________________ 18
CHAPTER II. IMAGING TECHNIQUES USED IN BILIOPANCREATIC EMERGENCIES ____________________________________ 20
II.1. ENUMERATION. PERFORMANCE. INDICATIONS. LIMITS ______________________________________________________________
II.2. DIAGNOSIS PROTOCOLS IN EMERGENCY _________________________________________________________________________
II.2.1. Biliary colic biliary lithiasis acute cholecystitis_________________________________________________________
II.2.2.Bile duct lithiasis acute cholangitis ___________________________________________________________________
II.2.3. Acute biliary pancreatitis_____________________________________________________________________________

20
26
26
27
29

CHAPTER III. ULTRASONOGRAPHY IN EMERGENCY AND CRITICAL CARE ___________________________________________ 30

III.1. DEFINITION OF THE METHOD _________________________________________________________________________________ 30
III.2. TECHNIQUES _____________________________________________________________________________________________ 30
III.3. SPECIFIC FEATURES OF THE ULTRASONOGRAPHIC EXAM IN EMERGENCY MEDICINE _______________________________________ 38
CHAPTER IV. CRITERIA OF SEVERITY ASSESSMENT FOR BILIOPANCREATIC EMERGENCIES AND THEIR IMPACT ON THE
DISEASE MANAGEMENT
_________________________________________________________ 42
CHAPTER V. GROUNDS OF RESEARCH ______________________________________________________________________________ 45
V.1. THE LIMITS OF CLINICAL DIAGNOSIS ____________________________________________________________________________
V.2. SPECIFIC ASPECTS OF EMERGENCY DIAGNOSIS ____________________________________________________________________
V.3. EMERGENCY IMAGING PRETENDING THE IDEAL SITUATION _______________________________________________________
V.4. MOBILE ULTRASONOGRAPHY _________________________________________________________________________________

45
46
46
47

PART TWO. PERSONAL RESEARCH _________________________________________________________________________________ 49

CHAPTER I. PURPOSE OF THE STUDY: PREMISES AND GENERAL OBJECTIVES _______________________________________ 50
CHAPTER II. METHOD _____________________________________________________________________________________________ 51
CHAPTER III. STATISTICAL METHODS______________________________________________________________________________ 53
CHAPTER IV. ULTRASONOGRAPHY AS A FIRST CHOICE IMAGING METHOD USED IN THE DIAGNOSIS OF
BILIOPANCREATIC EMERGENCIES (IST STUDY)______________________________________________________________________ 55
IV.1. OBJECTIVES ______________________________________________________________________________________________ 55
IV.2. MATERIAL AND METHOD ____________________________________________________________________________________ 55
IV.3. RESULTS ________________________________________________________________________________________________ 59

13

IV.4. DISCUSSIONS _____________________________________________________________________________________________ 77

IV.5. CONCLUSIONS ____________________________________________________________________________________________ 83
CHAPTER V. ULTRASONOGRAPHY IN BILIARY EMERGENCIES GALL BLADDER PATHOLOGY IIND STUDY ___________ 85
V.1. OBJECTIVES ______________________________________________________________________________________________ 85
V.2. MATERIAL AND METHOD ____________________________________________________________________________________ 85
V.3. RESULTS _________________________________________________________________________________________________ 87
V.4. DISCUSSIONS ____________________________________________________________________________________________ 100
V.5. CONCLUSIONS____________________________________________________________________________________________ 104
CHAPTER VI. ULTRASONOGRAPHY IN THE ACUTE DISEASES OF THE BILIARY DUCTS - IIIRD STUDY __________________ 106
VI.1. OBJECTIVES _____________________________________________________________________________________________
VI.2. MATERIAL AND METHOD ___________________________________________________________________________________
VI.3.RESULTS________________________________________________________________________________________________
VI.4. DISCUSSIONS ____________________________________________________________________________________________
VI.5. CONCLUSIONS ___________________________________________________________________________________________

106
106
108
113
115

CHAPTER VII. ULTRASONOGRAPHY IN ACUTE PANCREATITIS - IVTH STUDY ________________________________________ 116

VII.1. OBJECTIVES ____________________________________________________________________________________________
VII.2. MATERIAL AND METHOD __________________________________________________________________________________
VII.3. RESULTS ______________________________________________________________________________________________
VII.4. DISCUSSIONS ___________________________________________________________________________________________
VII.5. CONCLUSIONS __________________________________________________________________________________________

116
116
118
133
137

CHAPTER VIII. CONTRAST ENHANCED ULTRASONOGRAPHY IN ACUTE PANCREATITIS VTH STUDY _________________ 139
VIII.1. OBJECTIVES ___________________________________________________________________________________________
VIII.2. MATERIAL AND METHOD _________________________________________________________________________________
VIII.3. RESULTS ______________________________________________________________________________________________
VIII.4. DISCUSSIONS __________________________________________________________________________________________
VIII.5. CONCLUSIONS __________________________________________________________________________________________

139
139
145
163
169

CHAPTER IX. GENERAL DISCUSSIONS. DIAGNOSIS ALGORITHMS. THE ROLE OF ULTRASONOGRAPHY IN

BILIOPANCREATIC EMERGENCIES. _______________________________________________________________________________ 171
CHAPTER X. FINAL CONCLUSIONS AND PERSONAL CONTRIBUTIONS _______________________________________________ 176
BIBLIOGRAPHY __________________________________________________________________________________________________ 179

Introduction
The development and improvement of the ultrasonographic technique, as well as the possibility of performing
it in the emergency unit brought forth new practical evidence of the biliopancreatic diagnostic and therapeutic
management optimization. This represented the ground for choosing the topic of this research: CLINICAL AND
IMAGING CORRELATIONS WITH THE PURPOSE OF ESTABLISHING THE OPTIMAL THERAPY CONDUCT
IN BILIO-PANCREATIC EMERGENCIES.
The thesis aims to research the contribution of ultrasonography within the Emergency Department in improving
triage and diagnostic-therapeutic conduct. The study is organized in two major parts: a part that consists of a literature
data review and a part presenting the actual personal research.
PART ONE - PRESENT LEVEL OF KNOWLEDGE
The acute abdominal pain diagnosis in the emergency department represents one of the frequent diagnostic
challenges that the practicing faces, accounting for an average of 5% of the consultations. The technological evolution
and the increase of situations the medical team has to answer due to the pathological diversity led to the development of
mobile imaging devices and the defining of the term bedside ultrasound, a bedside exam of the critically ill patient.
Therefore ultrasonography in biliopancreatic emergencies develops as a binary way of thinking that is able to answer
the questions of the physician: a) is there biliary lithiasis or not?; b) are there complications of biliary lithiasis like acute
cholecystitis, choledolithiasis or acute pancreatitis?; c) what is the cause of jaundice?; d) what is the cause of abdominal
pain accompanied by shock: complicated aneurysm of the abdominal aorta, acute pancreatitis, acute cholangitis,
intestinal mesenteric infarction?

14

Ultrasonography is a quick diagnosis method in the emergency department, allowing for the triage of patients
with major emergency that require immediate surgery, from the patients that will undergo delayed surgery,
interventional procedures or conservative therapy, realizing at the same time a selection of the patients that need
further imaging investigations in order to establish the diagnosis. Emergency physicians have adopted ultrasonography
as a standard investigation in several critical syndromes in order to diminish the intervention duration and increase
diagnosis accuracy.
The treatment strategy in biliopancreatic emergencies requires a gradual assessment and an immediate and a
subsequent management depending on the severity of the disease and its complications as they were discovered during
the emergency evaluation. An optimal approach needs to estimate the risk using clinical, biological and imaging
parameters. Ultrasonography due to its accessibility provides the necessary data for the selection of the patients at risk
and their referral to gastroenterology centers.
The ideal situation in emergency must have a reference standard, represented by a criteria through which it is
decided weather the patient suffers from a disease or not. Using mobile, compact machines, ultrasonography offers the
possibility of a practical approach of the bedside examination (bedside ultrasonography), a goal highly desired by
emergency and intensive care physicians.
PART II - PERSONAL RESEARCH
The studys assumptions, hypothesis, material and method are all presented in detail in chapters I, II and III.
The objectives of the present research are:
1. Establish correlations between clinical and ultrasonographic criteria in biliopancreatic emergencies that will
allow the decrease of diagnosis errors in the emergency departments;
2. Identify and specify the performance of the ultrasonograhic technique in biliopancreatic emergencies in regard
with the following: disease diagnosis, complication diagnosis, prognosis;
3. Identify the necessary items for the development of a diagnostic algorithm, based on clinical and
ultrasonographical elements in biliopancreatic emergencies;
4. Critical analysis of ultrasonography in emergency units identify the main factors that decrease the
performance of the method or cause diagnosis errors.
A sequential research consisting of 5 studies, 3 retrospective studies and 2 prospective studies, was carried
through between August 2004 and July 2010. The subjects enrolled in the study were selected from the large mass of
patients who addressed the Emergency Department of Octavian Fodor Emergency Hospital, Cluj-Napoca. The
selected patients had to meet the criteria established for each of the areas of the research:
a. Ultrasonography as a first choice imaging method in biliopancreatic emergencies.
b. The role of ultrasonography in acute biliary disease
c. The contribution of ultrasonography in diagnosing acute obstructive biliary pathology;
d. An assessment of classic ultrasonographys use in the diagnosis and severity evaluation of acute pancreatitis;
e. The role of contrast enhanced ultrasonography in determining the severity of acute pancreatitis;
Chapter IV: Ultrasonography as a first choice imaging method in the diagnosis of
st
biliopancreatic emergencies - The I Study
Study Group A patients with a history of biliopancreatic emergency
This was an observational retrospective study that assessed the importance of ultrasonography in patients who
presented with acute biliopancreatic symptoms in the Emergency Department of Octavia Fodor Clinical Emergency
Hospital, Cluj-Napoca, between 6th of December 2005 and 30th of December 2006. A number of 759 patients, ages
between 17 and 90 years old, were admitted in the study.
Study Group B patients with therapy resistant ulcer-type dyspepsia
The study was an observational retrospective study that evaluated the role of ultrasonography in the diagnosis of
patients that might represent a biliopancreatic emergency while accusing an atypical clinical syndrome. The group
consisted of 358 patients who presented to the E.D., between 6 th of December 2005 and 30th of December 2006, with
ages ranging from 19 to 86 years old (2.39% of the total number of patients that presented to the E.D.) complaining of
symptoms characteristic for a therapy resistant ulcer dyspepsia upper abdominal pain syndrome. This study group was
selected from a number of 534 patients who presented these symptoms (3.55% of the total number of patients who
presented in the E.D.).

15

IV.R. Results
Study Group A
Descriptive analysis: The 759 patients who presented in the E.D. with biliopancreatic emergency symptoms
and were selected for the research had ages between 17 and 90 years old, with an average age of 56.67 16.76. A
significant prevalence of acute biliopancreatic pathology was noted after 20 years old that doubled among the 40 - 59
age group. (Table V)
Table V. The distribution of patients with biliopancreatic pathology enrolled in the study on age groups
Age group
Prevalence (%)
Growth rate
Ratio
<20 years (I)
0.79
20-39 years (II)
17.92
22.67
II/I
40-59 years (III)
34.26
1.91
III/II
60 years (IV)
47.04
2.63
IV/III
An inferential statistical analysis of the distribution of patients with biliopancreatic emergencies within the
study group revealed a weak statistically significant difference of acute biliopancreatic pathology among the age groups
in urban and rural males (2, p < 0.015892). As far as the females and the overall prevalence are concerned, statistically
significant differences were noticed between urban and rural patients: in women there is a statistically significant
predominance of this type of pathology in urban areas (2, p < 0.000990); the overall prevalence in both genders, in
urban areas, is significantly higher than in rural areas (2, p < 0.000013).
Biliary dyskinesia subgroup
The ultrasonographic exam performed within the first 2 hours after presenting in the E.D. showed the presence
of gall stones in only 4% of the patients with biliary dyskinesia symptoms, while 58% of the patients had normal
findings. In this subgroup there were no biliopancreatic emergencies that required immediate surgery.
Biliary colic subgroup
The ultrasonographic exam performed within the first 2 hours after presenting in the E.D. showed the presence
of gall stones in 85.96% of the patients, while 6.32 % of the patients did not present any ultrasonographic abnormalities.
Complications of cholelithiasis were revealed in 56.22% of the subjects. The complication that was most frequently
encountered was acute cholecystitis (34.66%).
Jaundice subgroup
The ultrasonographic evaluation of the patients with jaundice carried through within the first 2 hours from
presenting in the E.D. did not reveal abnormal ultrasonographic findings in 13% of the cases. Changes characteristic for
obstructive jaundice, with common bile duct and intrahepatic bile ducts dilatation, were found in 58% of the patients,
24% of these patients presenting a tumoral cause for the obstruction. Another aspect that was noticed in 19% of the
subjects with jaundice, who also complained of biliary colic, was that of recent passage of common bile duct, without
dilatation of the intrahepatic bile ducts while presenting cholelithiasis with calculi measuring less than 5 mm or up to 10
mm. A significant percentage of patients (10%) presented choledocolithiasis after cholecistectomy.
Acute pancreatitis subgroup
In 34% of the patients with acute pancreatitis the ultrasonographic evaluation did not show changes of the
pancreatic lodge. Ultrasonographic aspects that raised the suspicion of acute pancreatitis in 27% of the patients were
size and structure changes. Findings characteristic for severe acute pancreatitis, like fluid collections in the pancreatic
lodge, peripancreatic fluid and in distant areas, were observed in 29% of the subjects; 4% of the patients included in this
subgroup presented immature pseudo cysts.
The risk of presenting ultrasonographic changes during an emergency exam as well as the risk of having a
complication that required surgery was analyzed using the Odd Ratio test. An increased risk for developing a
complication of lithiasis (OR=19.1) that could be depicted by ultrasonography and that needed surgical treatment
(OR=109.32) was discovered in patients with biliary colic. The patients with jaundice also present a higher risk for a
surgical complication (OR=22.38).
An analysis of the value of ultrasonography in diagnosing gall stones and the complications they produce
proved to have 91.35 % sensitivity and a low specificity (55.05%). The positive predictive value of the method was
93.87% and the negative predictive value was 45.79%. The analysis of ultrasonographys diagnostic value, using
Likelihood ratio + (positive test result) of 2.03 and Likelihood ratio - (negative test result) of 0.17, revealed a good
power of the diagnostic method in the positive prediction of the diagnosed pathologies, with a decreased risk of
ultrasonographically underestimate the present changes.

16

Study group B
The group included patients with ages between 15 and 90 years old, with an average age of 49.26 18.14. The
ultrasonographic exam performed within the first 4 hours from the presentation at the E.D. showed the presence of
biliopancreatic changes that had potential to influence the symptoms in 25.98 % of the patients. Ultrasonography
revealed that an important percentage of patients (36.31%) presented pathological changes of the digestive tract that
explained their resistance to antisecretory therapy that was given in the E.D. There was also noticed a high incidence
(17.32%) of biliary changes found during the ultrasonographic exam in the patients accusing epigastric pain.
The risk of finding biliopancreatic pathology during the ultrasonographic exam in the subgroups that presented
epigastric or right upper quadrant pain was analyzed using the Odd Ratio test. An OR of 1.53 (95% CI: 0.87 - 2.69) was
obtained for the patients with ulcer type dyspepsia compared with an OR of 0.94 (95% CI: 0.24 - 3.60) obtained for the
patients with upper quadrant pain. The analysis of these data corroborated with the results of the treatment management
showed that, when performed in emergency, ultrasonography was able to indicate the patients with high risk of
requiring surgery from ulcer type dyspepsia subgroup, OR=3.84 (95% CI: 0.47 31.16).
nd

Chapter V: Ultrasonography in biliary emergencies gall bladder pathology II

Study

The second study was an observational retrospective study that assessed the role of ultrasongraphy in patients
symptomatic gallstones who presented in the E.D. of Octavian Fodor Emergency Hospital, Cluj-Napoca.
V.3. Results
The study group consisted of 179 patients with an average age of 59.31 15.82 years old. In the group of
patients diagnosed by ultrasonography with acute cholecystitis the pathological types of cholecystitis found during
surgery were analyzed and an important percentage (48%) of complicated types, phlegmonous and gangrenous, was
observed.
The ultrasonographic exam in E.D, gives information on the wall changes, like increased wall thickness, double
contour, pericholecystitis or the presence of pericholecystic fluid. Wall thickening is the most frequent finding within
the group with acute cholecystitis (Table XXXVI). Another analyzed issue was the agreement between the size of the
calculi determined by ultrasonography and the size measured after surgery. A good correlation of these measurements
was obtained (40.24%), while there still is an important percentage of cases (29.89%) in which the size of the calculi
was underestimated when determined ultrasonographically. An important observation for the medical practice is the low
percentage of patients with wall changes suggestive of cholecystitis who were diagnosed with microlithiasis during the
ultrasonographic exam (1.22%).
The analysis of statistical significance using Risk Ratio (RR) and Odd test (OR) showed a high risk of
developing catarrhal cholecystitis (RR=1.19; OR=1.32, 95% CI 0.71 - 2.44) and chronic cholecystitis (RR=1.53;
OR=1.66 95% CI 0.72 3.79) in patients who were known with biliary lithiasis. The subgroup of patients who were
not diagnosed with gall stones prior to their presentation in the E.D. for the acute episode have a higher risk to develop
phlegmonous or gangrenous forms of cholecystitis (RR=1.32; OR=1.69 95% CI 0.93 3.09). The contribution of the
ultrasonographic technique in diagnosing gallstones and complications like acute cholecystitis in emergency situations
was further evaluated.
For the diagnosis of gall stones in the presence of acute cholecystitis the sensitivity of the method was 100 %,
the specificity 98.7%, the PPV was 98.7% and the NPV was 100%, with an accuracy of 93.39%. The LR + value was
76.9, demonstrating a high probability for the presence of biliary lithiasis if the ultrasonography was positive. In the
diagnosis of acute types of cholecystitis a sensitivity of 89.99%, a specifity of 84.44%, a PPV of 88.31% and NPV of
86.09% was obtained with an accuracy of the method of 87.35%. The originality of this research resides in the
correlation of the clinical and ultrasonographical aspects with the intraoperative findings and the analysis of
ultrasonographic method in diagnosing the various pathological subtypes of acute cholecystitis.
Table XXXVI. The incidence of gall bladder parietal changes observed during ultrasonography
Related to the total number of patients with cholecystitis
Catarrhal
Phlegmonous
Gangrenous
Chronic
Ultrasonographic findings (%)
colecystitis
cholecystitis
cholecystitis
cholecistitis
Wall thickness > 4 mm

20.89

18.99

20.89

10.76

Double contour

13.29

16.46

20.25

5.70

Pericholecystitis

3.16

8.23

9.49

0.63

Pericholecystic fluid

1.27

1.90

3.80

0.00

17

rd

Chapter VI: Ultrasonography in acute disease of the biliary ducts III Study
This was a prospective study that assessed the importance of ultrasonography in patients with obstructive
jaundice who presented in E.D. of Octavian Fodor Emergency Hospital, Cluj-Napoca, between February 2005 and
March 2005.
VI.3. Results
The study group included a number of 31 patients (16 female and 15 male) with obstructive jaundice diagnosed
in E.D., with ages between 29 and 89 years old, an average age of 58.06 13.76 years old, 55.56 14.60 years old in
the female group and 60.73 12.75 years old in the male group.
The ultrasonographic exam performed in the E.D. was able to visualize the biliary duct dilatations cause by the
obstruction, but were not able to determine the cause of the obstruction in 41.93% of the cases. A comparative analysis
of the etiological diagnosis of the obstruction, suspected ultrasonographically, and the endoscopic diagnosis, established
during the endoscopic retrograde cholangiopancreatography, showed a weak statistically significant difference in the
sense of a positive correlation of the investigations (MW, p=0.02659). There were not statistically significant
differences between the size of the common bile duct measured through ultrasongraphic examination and through
endoscopic retrograde cholangiopancreatography (MW, p=0.832748). It was proved that ultrasonography is useful in
the E.D. for the appreciating the size of the bile ducts and can also be used to dynamically evaluate them.
Ultrasonography was able to visualize the presence of calculi within the bile duct in 32.25% of the cases, while
endoscopic retrograde cholangiopancreatography confirmed it in 48.38% of the patients.
The analysis of ultrasonographys role in diagnosing obstructive lithiasis of the common bile duct determined a
sensitivity of 66.66%, a specificity of 51.61 % and a diagnosis accuracy of 56.6%. The positive predictive value was
40%, the negative predictive value was 76.19%, with a Likehood ratio + of 1.32 and Likehood ratio - of 0.64.
th

Chapter VII: Ultrasonography in acute pancreatitis IV Study

The present study will analyze the contribution of ultrasonography performed in the E.D. in evaluating patients
with clinical suspicion of acute pancreatitis and the triage of the patients with severe pancreatitis.
This study was an observational retrospective study that evaluated the role of ultrasonography in diagnosing acute
pancreatitis and its complications in the patients who presented in the E.D of Octavian Fodor Emergency Hospital,
Cluj-Napoca, between August 2005 and December 2006.
VII.3. Results
The study group consisted of 95 patients with acute pancreatitits, ages between 23 and 85 years old, an average
age of 50.55 14.20 years old and mostly males, with a male/female ratio of 1.96.
Acute pancreatitis etiology analysis within the study group showed that alcohol abuse was the main cause in
42.11 % of the patients. The leading causes of pancreatitis, long standing alcohol consumption and biliary stone disease,
were found in 75.8% of the patients, while in 6.32 % of the cases the etiology could not be determined. It was also
observed that the subjects who address the E.D. within the first 6 hours from symptoms onset belonged to the 40-59
years old age group (10.87%)
The ultrasonographic evaluation performed in the E.D. was able to assess the pancreatic lodge in 85.6% of the
patients and in 76.84% of the cases structure and echogenicity changes were described. In 14.74 % of the patients with
acute pancreatitis the pancreatic lodge could not be evaluated due to the presence of an inadequate acoustic window.
Analyzing the severity of acute pancreatitis using severity scores, ultrasonographic findings and the dynamic evolution
of the biochemical parameters, the statistical significance of the severity scores (BISAP, HAPS, Ranson, SIRS) and of
the presence of fluid collections found through ultrasonography was evaluated. Highly statistically significant
parameters were demonstrated within the acute pancreatitis study group for the severe type of pancreatitis (Fischer Test,
p=0.0000): the presence of more than 2 fluid collections found on the ultrasonographic exam, more than 20 breaths/min,
fever higher than 380C, SIRS positive, pleural effusion determined ultrasonographically, leukocytosis > 16000/mm 3,
ASAT > 250U/l. Therefore a new emergency clinical-biochemical-ultrasonographic score for the triage of patients with
severe forms of pancreatitis, who need to be sent to specialized gastroenterology units, is being proposed.
Clinical Parameters: 1. Breaths/min > 20 1 point; 2. Fever > 38C - 1 point; 3. Positive for SIRS 1 point;
Ultrasonographic parameters: 4. The presence of more than 2 fluid collection during ultrasonography 1 point; 5.
Pleural effusion found ultrasonographically- 1 point;

18

Biochemical Parameters: 6. Leukocytosis > 16000/mm3 - 1 point; 7. ASAT > 250 UI/l - 1 point
It is considered that specific gastroenterology therapy is indicated when three parameters, one of each
category, are present or when there is an association of ultrasonographic parameters with one clinical parameter. The
proposed score needs to be validated on a larger number of patients or on support evidence for the presence of
pancreatic necrosis available in emergency situations.
th

Chapter VIII: Contrast enhanced ultrasonography in acute pancreatitis V Study

The present study refers to the contribution of contrast-enhanced ultrasonography in evaluating the severity of
acute pancreatitis. This was a prospective study on a number of 25 patients who were admitted in the Emergency
Department of Octavian Fodor Emergency Hospital, Cluj-Napoca, between December 2008 and July 2010. The
subjects were selected based on the clinical findings, the biochemical confirmation of acute pancreatitis and the results
of the B mode ultrasonographic evaluation.
VIII.3. Results
A descriptive analysis of the 25 patients selected for contrast enhanced ultrasonographic examination revealed a
mean age of 46.16 13.99 years old. The evolution of the subjects from the study group showed the presence of
multiple organ failure (MSOF) signs in 12 % of the patients. The analysis of the biochemical parameters significant for
describing pancreatic inflammation and necrosis in the ED and later on showed the presence of leukocytosis in 80% of
the patients, 44% of them had over 16000/mm3, while the mean value was 15006.4 7122.07 leukocytes/mm3. Creactive protein (CPR) determined after 48 hours from presentation was elevated (10.34 8.98 mg/dl).
The transabdominal ultrasonographic exam revealed that all the patients with acute pancreatitis selected in the
study presented changes of the pancreatic lodge with alterations of structure and echogenicity. In 8% of the cases a
well-defined capsular contour around the pancreatic parenchyma was visualizes, while 92 % of the patients presented a
hazy contour of the gland. Fluid collections with various localizations were found in 64 % of the cases, 28 % in the
pancreatic lodge and 56% around the pancreatic area. Qualitative findings using contrast enhanced ultrasonography
revealed acute hemorrhagic pancreatic necrosis in 76 % of the subjects. In 12 % of the cases the acoustic signal after
contrast media injection was delayed and presented a moderate decrease of acoustic intensity. The examination allowed
the identification of the pancreatic capsule in 20% of the patients, while 64 % of them presented inflammatory changes
within the pancreatic parenchyma. Contrast enhanced ultrasonography identified new collection in 20 % of the cases,
defining the presence of an effusion in 56 % of the subjects admitted in the study.
The mean value of the maximum gradient reached within the first 40 seconds after contrast media injection was
19.37 8.53 dB in the superior mesenteric artery (SMA. An acoustic signal was also determined in the inflammation
areas with a slightly reduced value of the acoustic intensity (14.76 6.70 dB) compared with the value obtained in
SMA. At the same time the mean value of the gradient was considerably reduced in the necrosis areas (8.97 9.28 dB)
compared with the SMA value. The same thing was noticed in the hypovascular areas where the gradient presented
intermediary values between those obtained in the necrosis and inflammation areas. The statistical analysis of the
maximum gradients determined in SMA and in the inflammation, necrosis and hypovascular areas of the pancreas
showed statistically significant differences (KW, p=0.0008), with a statistically significant variation probability (F test,
p=0.001). These results may represent practical ultrasonographic evidence for distinguishing the degree of pancreatic
necrosis or the magnitude of the inflammation.
A measurement of the time needed to reach the maximum gradient in the first 40 seconds after contrast media
injection was determined. The result was that there are no statistically significant differences between the mean value in
the SMA (15.85 4.60 sec.) and the inflammation areas (15.15 3.20 sec.), both sites having a low standard deviation,
which confirms the a distribution homogenicity of the values. In the necrosis areas the mean value of the time needed to
reach the maximum gradient was significantly higher (22.69 7.55 sec) compared with the SMA.
The statistical analysis of the time needed to reach the maximum gradient in the SMA and in the inflammation,
necrosis and hypovascular areas of the pancreas revealed statistically significant differences (KW, p=0.0006), with a
high probability of having the same variation (F test, p=0.00004). This finding is concordant with the result of the
statistical analysis of the maximum gradient after contrast media injection in areas with similar parenchyma structure
that are altered as a result of the acute pancreatitis.
The analysis of the wash in AC value in the first 40 sec depicted statistically insignificant differences between
the SMA and the inflammation areas (KW, p=0.0802). Comparing the values in the SMA and the values obtained when
the region of interest (RI) was placed in inflammation, necrosis or hypovascular areas weak statistically significant

19

differences (KW, p=0.0115) were discovered. A rise of the AC values with the degree of necrosis was noticed, a finding
that was concordant with the prolongation of the time necessary to reach the maximum gradient.
A compared analysis of the wash out AC variation within the 40-80 sec time interval after contrast media injection,
showed statistically significant differences (KW, p=000.8) between the structurally altered pancreatic areas and the
SMA. Furthermore a delayed wash in was observed with a peak of acoustic intensity in the 60-100 seconds time
interval, in 72 % of the cases being found after 80 seconds. This is an occurrence not previously described in literature.
It was also revealed that the agreement between the percentage of necrosis determined through ultrasonography and the
one determined through computed tomography reached 60 %.
The correlations between the percentage evaluation of necrotic area determined ultrasonographically and the
number of collections also diagnosed by ultrasonography showed a positive correlation moderately statistically
significant (S, p=0.0009). This proves the parallelism between the increase of the pancreatic necrosis degree and the
number of fluid collections. It was also noticed that there is positive correlation between evolution severity, the total
number of fluid collections (p=0.00001), the effusion aspect (p=0.00001) and the presence on pleural collections
(p=0.00001) that is highly statistically significant.
The assessment of the ultrasonogrphic technique in diagnosing acute hemorrhagic pancreatic necrosis found a
sensitivity of 76%, a specificity of 100% and an accuracy of 100%.
The present research showed a particular aspect of delayed vascularisation in the areas with lesion
polymorphism and necrotic surrounding areas, a finding with practical implications in evaluating the areas of residual
parenchyma and the local circulatory alterations induced by SIRS. This phenomenon was not previously described in
literature. It was noticed that the hypoechoic areas frequently represent complete or partial necrosis, accompanied by
residual normal parenchyma, often associated with inflammation. These qualitative ultrasonographic observations
underline the contribution of CEUS in the triage of patients with severe forms of acute pancreatitis.
A clinical-biochemicalultrasonographic score was proposed for the emergency triage of severe acute pancreatitis
(STCBUSC):
Clinical parameters: 1. Breaths/min > 20 1 point; 2. Fever > 38C - 1 point; 3. Positive for SIRS 1 point;
Ultrasonographic parameters: 4. The presence of 2 or more fluid collection found ultrasonographically 1 point; 5.
Ultrasonographic pleural fluid collection - 1 point;
Ultrasonographic parameters CEUS exam: 6. Pancreatic necrosis 1-3 points (CT analogy: <30% - 1point.; 3050% - 2 points.; >50% - 3points.); 7. Peripancreatic and distance effusions 1 point;
Biochemical parameters: 6. leukocytosis > 16000/mm3 - 1 point; 7. ASAT > 250 UI/l - 1 point;
For an accurate triage of severe cases of acute pancreatitis that require referral to a specialized centre on
gastroenterology intensive care it is necessary to specify the presence of pancreatic necrosis visualized through contrast
enhanced ultrasonography along other three parameters, with al least one biological parameter and one clinical
parameter that proves the acute pancreatic changes. The lowest score mandatory for a patients referral to intensive care
gastroenterology is 4. This score has to be validated and the perhaps the cut-off values have to be optimized on a
larger number of patients.
Chapter X: Final conclusions and personal contributions
The studies presented in this thesis represent the first national statistical communication on the role of permanent
access to ultrasonography in E.D., with the purpose of evaluating its diagnosis contribution, prognosis capacity and the
use of biliopancreatic emergency triage protocols.
1. The descriptive analysis of the study group epidemiology data revealed aspects of primary medical care that
need further improvement:
High incidence of biliary emergencies in female subjects from urban areas.
High incidence of acute pancreatitis in male subjects from urban areas.
High incidence of functional disorders like biliary dyskinesia in urban female subjects.
The patients enrolled in the studies were predominantly coming from urban areas, an aspect that raises the
issue of risk factors or that of reduced access of the rural population to emergency services.
The delayed presentation of the patients in the E.D. represents a primary medical care issue as well as a health
education problem.
The reduced compliance for surgery, especially in the rural patients, raised the issue of the lack of health
education.

20

The finding of a high percentage of subjects (55.11%) with ultrasonography positive for acute cholecystitis in
the presence of biliary lithiasis, but who were not aware of their pathology prior to the acute event,
demonstrates the absence of a widespread screening at the primary medical care level.
2. The statistical analysis of the performance demonstrated by the ultrasonographic exam proved it to be an easy
and absolutely necessary method in assisting biliopancreatic emergencies:
Study I: Biliopancreatic emergencies
a. Diagnosis of biliary lithiasis: - sensitivity 91.35%, LR- 0.17;
b. Detection of immediate surgery necessity: OR=109.32 in the subgroup with biliary colic;
c. Appreciation of the risk of pancreatic complication caused by biliary stone disease: OR=3.4 if calculi
under 10 mm were visualized in the gall bladder.
Study II: Acute cholecystitis
a. Detection of biliary lithiasis sensitivity 100%, diagnosis accuracy 93.39%, LR+ 76.9;
b. Detection of acute types of cholecystitis specificity 84.44%, NPV 86.09%, diagnosis accuracy
87.35%;
c. Study III: Acute pathology of the common bile duct
d. Obstruction diagnosis sensitivity 100%
e. Cause of obstruction detection sensitivity 66.66%, NPV 79.19%;
Study V: Acute pancreatitis CEUS exam
a. Detection of severe forms of acute pancreatitis (necrosis): sensitivity 76%, diagnosis accuracy
100%.
3. Analyzing the correlation of clinical symptoms with the result of the ultrasonographic exam demonstrated
the role of ultrasonography in detecting the complications of biliary stone disease in patients presenting with a
nonspecific upper abdominal pain syndrome.
4. The correlation of the ultrasonographic findings with the endoscopic retrograde cholangiopancreatography
exam revealed the utility of the method in monitoring the dynamic of biliary duct measurements with acute obstruction
before and after interventional therapy.
5. Corroborating the clinical, biochemical and ultrasonographic data with the severity of the acute pancreatitis,
appreciated by the number of days of hospitalization, allowed a selection of parameters that can characterize a new
severity score in acute pancreatitis.
The practical value of the research implementation possibilities
6. The research demonstrated the epidemiology risk factors (age over 50, rural areas and feminine gender) and
the ultrasonographic risk factors (calculi under 10 mm and an aspect of recent passage by calculi of the common bile
duct) caused by the complications of biliary lithiasis in the geographic area where the study was carried through.
7. A standard protocol was proposed, based on the practical evidence of biliopancreatic management in E.D., a
protocol adapted to the health system, which facilitates the triage of surgical patients and eases the diagnosis-therapeutic
approach.
8. A clinical-biochemical-ultrasonographic triage score of the severity of acute pancreatitis was also proposed,
based on practical evidence and using easy to obtain parameters, that can be determined in the E.D.: breaths/min > 20;
fever > 380C; positive for SIRS; leukocytosis > 16000/mm3; ASAT>250; the presence of more than 2 fluid collections
discovered on the ultrasonographic exam; pleural fluid collection found ultrasonographically.
9. The introduction of contrast enhanced ultrasonographic examination in the evaluation of acute pancreatitis
reveals an increase of diagnosis accuracy in severe forms and optimizes the clinical-biochemical-ultrasonographic triage
score of severe forms that require gastroenterology intensive care assistance.
10. The quantitative analysis of the dynamic contrast media uptake parameters in the altered areas of
parenchyma (inflammation, necrosis, hypovascular or delayed vascularisation areas) allows the identification of the
residual parenchyma.
11. The evaluation of CEUS creates the premise for the development of rheologic studies and matrix analysis
of the local and distant vascular changes in the presence of acute pancreatic inflammation with an impact on therapy
and prognosis.
Contribution to the medical decision-making
12. B mode and contrast enhanced ultrasonographic examinations, by diagnosing the morphological alterations
caused by the presence of biliary lithiasis or the action of other etiology factors on the pancreatic parenchyma and on
the gall bladder, represents a quick tool for diagnosis and biliopancreatic complications screening, having an evidence
based therapy approach.

21

CURRICULUM VITAE
1. Last name: GOLEA
2. First name: ADELA
3. Date and place of birth: 28.10.1970, DROBETA-TURNU-SEVERIN, MEHEDINTI
4. Citizenship: ROMANIAN
5. Marital status: SINGLE
6. Education:
Iuliu Haieganu University of
Medicine and Pharmacy, Cluj-Napoca

Institution

Babe-Bolyai University,
Cluj-Napoca
Duration: from (month, year) Sept. 1989 Jul. 1995
until (month, year)
Febr. Jul.1997
Academic degrees or
Doctor - physician
diplomas
Pedagogy

Medical Highschool
Drobeta Turnu Severin

Pedagogy High school design,

Drobeta Turnu Severin

Sept. 1985 Jul. 1989

Sept. 1977 Jul. 1985

Nurse

7. Professional experience:
Duration:
Jan. 1996- Apr. 1999- Aug. 1999 - May 2008
Mar. 1999
Jul. 1999

May 2008
present

Place:

Cluj-Napoca

Institution:

Position:

ClujNapoca
County
Hospital

DrobetaTr.-Severin
County
Hospital
ED

Cluj-Napoca
The Clinical Hospital for Adults
ED
Centre
for
Formation
Ultrasonography

- Sept. 2007- present

Emergency
County
in Hospital, EDSMURD

Resident in Specialist in MD (2004)

Emergency Emergency Certificate of Competence in General
Medicine
Medicine
Ultrasonography
Certificate of Competence in Health
Care Management
Training
in
Ultrasonography,
Emergency Medicine
Educational projects/research

MD
Project
Management
Cooperation
with
Iuliu
Haieganu
University of
Medicine and
Pharmacy,
Cluj-Napoca

Cluj-Napoca
Iuliu
Haieganu
University of Medicine
and Pharmacy
Department of Emergency
Medicine
Associated
teaching
assistant (sept. 2007)
Assistant professor (March
2009)

8. Doctoral school: Imaging Department, enrolled in 01.11.2004, PhD coordinator Prof. Dr. Radu Badea, title:
Clinical and Imaging Correlations with the purpose of establishing the optimal therapy conduct in biliopancreatic
emergencies.
9. Present employer and occupied position: Iuliu Haieganu University of Medicine and Pharmacy, ClujNapoca Assistant Professor; Emergency Department, Clinical Emergency County Hospital, Cluj-Napoca - MD
10. Member of the following professional associations: Member of the Romanian Society of Emergency
and Calamity (SMUCR) since 1997, Vice-president of SMUCR, Cluj-Napoca between 2002 and 2008; member of the
European Society for Emergency Medicine (EUSEM) since 2008; member of the Romanian Society of
Ultrasonography in Medicine and Biology (SRUMB) since 2001; member of the European Federation of Societies for
Ultrasound in Medicine and Biology (EFSUMB) since 2002; member of the American Association for the
Advancement of Science in 2003; Romanian College of Physicians
12. Foreign languages: English intermediate level, French beginner level
13. Other proficiencies: Interventional ultrasonography, Cardiac ultrasonography, Paediatric emergencies,
Radio pathology medical intervention in radiation emergencies or nuclear accidents, Clinical electrocardiography,
Catastrophe Medicine
14. Awards received as recognition of professional and scientific activity: The Award of Romanian Society
of Ultrasonography in Medicine and Biology for a poster presentation at the National Ultrasonography Conference,
Constana , Romania, May 2003; The Prize for involvement and supporting the REMSSy IV program during 2003 and
2007, December 2007; Gheorghe Jovin Award, received by the CECUS team of the University of Medicine and
Pharmacy, Cluj-Napoca at EUROSON, Timisoara, Romania, June 2008.

22

17. Participation in scientific events: 20 oral presentations/posters in national scientific events; 11 oral
presentations/posters in international scientific events
18. Postgraduate courses in Romania and abroad: 35
19. Postgraduate courses lecturer in various conferences: 11.04. 12.04.2007: The First International Course
of Ultrasonography for Anaesthesia and Intensive Care Practice, Cluj Napoca; 28.06.2007: Ultrasonographic
Techniques in Emergency Medicine, at The National Conference of the Romanian Society of Emergency Medicine and
Calamity, Iasi Romania; 02.12.-05.12.2007: Ultrasound in Emergency and Critical Care Medicine, Timioara;
15.06.2008: Practical Ultrasonography Course for Intensive Care Physicians at the Romanian and German Intensive
Care Physicians Assembly, Cluj-Napoca, Romania; 21 aprilie 2009: Implementation course of the Guide for diagnosis
and treatment of ST elevation myocardial infarction, Cluj-Napoca.
20. Published books: Coordinating Editors R. Badea, S. Dudea, T. Suteu, A. Golea, ULTRASONOGRAPHY
IN MEDICAL AND SURGICAL EMERGENCIES: I. FAST. II. EMERGENCY ULTRASONOGRAPHY, Alpha
publishing, 2006, edited as part of the REMSSY Rehabilitation Program of the Emergency System level IV, ISBN
(10) 973-7871-45-9, cod CNCSIS 285
21. Chapters published in volumes written by a group of authors:
I. Adela Golea, Titus uteu, Radu I. Badea, Chapter 26 Ultrasonography in vital emergency and critical care
evaluation. The FAST Technique in The Comprehensive Guide of Clinical Ultrasonography, III rd volume, Locomotion
System, Paediatrics Ultrasonography, Interventional Ultrasonography, Progresses and New Concepts in
Ultrasonography, Ed. Medical Bucureti, pg. 686-695, 2008
II. Horea tefnescu, Adela Golea, Radu I. Badea, Chapter.28 Telemedicine and e-health solutions applied in
ultrasonography in The Comprehensive Guide of Clinical Ultrasonography, III rd volume, Locomotory System,
Paediatrics Ultrasonography, Interventional Ultrasonography, Progresses and New Concepts in Ultrasonography, Ed.
Medical Bucureti, pg. 705-713, 2008
III. Ioan Stoian, Radu Badea, issuing team: SC IPA SA, University of Medicine and Pharmacy Iuliu Haieganu Cluj
Napoca The Centre for Training in Ultrasonography (P. Mircea, S. Dudea, Adela Golea, Carolina Botar Jid, T. Vasile,
T. uteu), The Institute Of Urology and Transplantation, Cluj-Napoca, University of Medicine and Pharmacy, Trgu
Mure, The cooperative system applied in emergency and catastrophe medicine, Ed. Digital Data Cluj 2008, ISBN 978973-7768-46-9
22. Articles published in extenso in journals indexed in international databases:
I. Adela Golea, Radu Badea, Mihai Socaciu, Brndua Diaconu, Daniela Iacob. Quantitative analysis of tissue perfusion
using contrast-enhanced transabdominal ultrasound (CEUS) in the evaluation of the severity of acute pancreatitis.
Medical Ultrasonography 2010, 12(3): 198-204
II. Clin Mitre, Adela Golea, Iurie Acalovschi, Teodora Mocanu, Ana Maria Caea. Ultrasound-guided external jugular
vein cannulation for central venous access by inexperienced trainees. Eur J Anaesthesiology 2010; 27:300-303
III. Adela Golea, Radu Badea, Titus uteu, Lidia Ciobanu, Teodora Surdea-Blaga. The contribution of
ultrasonography to the diagnostic-therapeutic triage of the biliopancreatic emergency. Medical Ultrasonography 2009,
11(3): 41-49
IV. A. Golea, Radu Badea, Mihail Socaciu. Processing of wash-in/wash-out curves and signal intensity ultrasound in
contrast enhancement ultrasound support for new computer models for optimizing the diagnosis and therapeutic
management of acute pancreatitis. IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2010 (THETA 17). pg.258-262
V. D. Capatina, O. Dancea, R. Cazan, A. Golea, C. Boeriu, A. Stoian, Using the cooperative robots concept in
emergency and catastrophes medicine, IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2008 (THETA 16), IEEE Catalog number CFP08AQT-PRT, pg. 134-138 (IEEE/ISI covered, IEEE
Explore indexed), ISBN 978-1-4244-2576-1
VI. I.Stoian, A. Golea, R. Badea, A. Moldovan, O. Dancea, C. Posteuca, Using the cooperative robots concept in
emergency and catastrophes medicine, IEEE TTTc International Conference on Automation, Quality and Testing,
Robotics AQTR 2006 (THETA 15), IEEE Catalog number 06EX1370, pg. 415-419 (IEEE/ISI covered, IEEE Explore
indexed), ISBN 1-4244-0360-X
23. Articles published in extenso in national recognized journals:
I.T. uteu, R. Badea, Adela Golea, Monica Lupor Morgovan, The diagnostic role of ultrasonography in the evaluation
of the acute epigastric pain, Romanian Journal of Ultrasonography, Vol.8, nr.4,pg.219-227, 2006, ISSN 1454-5829,
CNCSIS 126 D category.
II.Adela Golea, T. uteu, H. Branda, T.Vasile, R. Badea, The diagnostic role of ultrasonography in the evaluation of
posttraumatic liver pathology. The importance of the matter image illustrated, Romanian Journal of Ultrasonography,
Vol.8, nr.1-2,pg.21-27, 2006, ISSN 1454-5829, CNCSIS 126 D category.
III.Diana Dumitracu, M. Varga, A. Nicolaenco, C. Bodolea, C. Zdrehus, E. Kallo, G. Pit, A. Golea, Fatal
anaphylactic shock to Penicilin: case presentation and literature data. Clujul Medical, vol.LXXIV, nr.1-2, ISSN 12222119, pg.136-140, 2000, CNCSIS 253 B category.

23

24. Articles published in extenso in volumes of national manifestations:

I.Adela Golea, Radu Badea, Ultrasound monitoring in acute pancreatitis, The Romanian Journal of Anaesthesia and
Intensive Care, vol.15, suppl.2, 2008, ISSN 1582-652X, pg. 36-40, CNCSIS 203 B+ category.
II.Adela Golea, Emergency Ultrasonography FAST Technique, Romanian Journal of Ultrasonography, Vol.9, Supl.1,
pg.133-135, 2007, ISSN 1454-5829, CNCSIS 126 D category.
25. Compact disks, other teaching materials:
I.Adela Golea. Program e-learning: http://www.e-sanatatepublica.ro/index.php/Cont: ULTRASOUND IN MEDICAL
AND SURGICAL EMERGENCIES. PART I. GENERAL ULTRASONOGRAPHY FAST, published as part of the
Rehabilitation of the Romanian Emergency Care System REMSSY, level IV, 2007.
II.Authors: medical: Dr.Adela Golea, technician: physicist Clin Cpraru; Medical Coordinators: proof. dr.R. Badea,
dr. T. uteu, conf. dr. A. Costache, ef de lucr.Dana Elena Nedelcu, teaching assisstant dr. Irina Jari, CD: Emergency
Ultrasound - FAST, released as part of the Rehabilitation of the Romanian Emergency Care System REMSSY, level
IV, The Centre for Training and Research in Ultrasonography of the Iuliu Haieganu University of Medicine and
Pharmacy, Cluj-Napoca, The Centre for Health Services, Bucureti, 2006, ISBN (13)978-973-7871-46-6
III.T. uteu, A. Golea, CD: Applications of ultrasonography in abdominal emergencies, Aplicaii ale ecografiei n
urgenele abdominale, images with comments: The Centre for ultrasonography training, Ed. Universitii de Medicin
i Farmacie Cluj-Napoca, 2004, ISBN 973-693-049-1, cod CNCSIS 146
26. Experience in research projects and programmes and in professional training
Programe/Project
Position
Period:
1.SonoDig: Idea Programme CNCSIS: 833/2008

researcher

2009 -2010

2. SIMTECH: Cnmp partenerships 4446/2008

researcher

1/10/2008
30/09/2011
2007 - 2009

3. Implementation of total IV anaesthesia researcher

CNCSIS:2193/09.2007
4.REMSSy IV Romanian-Swiss Programme:
Lecturer;
2006 - 2007
Sub-programme
supervisor
Emergency Ultrasonography
FAST
5.COOPURG: Telemetric system with cooperative Scientific coordinator
15.10.2005
mobile intervention units applied in emergency and
30.06.2008
catastrophe medicine CoopUrg, CEEX: 4/2005
6. Matra-KAP Programme
7.REMSSy III Romanian-Swiss
(Rehabilitation of the Romanian
Medical Care System)

Data base administrator

Programme Lecturertraining programme
Emergency

24

01.09.200431.12.2006
2004 - 2005

Present
status
running
- running
running
finished

- finished

finished
finished